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).

Nursing homes have traditionally been large institutions. Smaller community versions were developed around the 1970s.Janicki, M., Krauss, M. W., & Seltzer, M. (1988). "Community Residence for Persons with Developmental Disabilities: Here to Stay". Baltimreo, MD: Paul H. Brookes.Racino, J. & Schwartz, D. (1978). Founding of the Education Committee of the New York State Association of Community Residence Administrators with funding from the One-to-One Foundation Some "community living" (CL) groups advocated for a different type of care and funding, which resulted in the creation of assisted living facilities.Racino, J. & Heumann, J. (1992). Independent living in the community: Building coalitions among elders, people with disabilities and our allies". In: E.F. Ansello & N. Eustis, "Aging and Disabilities: Seeking Common Ground". Amityville, NY: Baywood Publishing Co.

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.Consortium of Citizens with Disabilities. (2012). "Long-Term Task Force on Services and Supports". Washington, DC: Author.

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.Biklen, Douglas. & Knoll, James (1987). "On the Use of Nursing Homes as a Residential Option for People with Developmental Disabilities in the State of Wisconsin". Syracuse, NY: Community Integration Project, Center on Human Policy [funded by the National Institute on Disability Research and Rehabilitation]General Accounting Office. (1987). "Medicaid: Addressing the Needs of Mentally Retarded Nursing Home Residents". Washington, DC: Author.

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.Holder, E. (1981, October). "Medicaid Discrimination in Long-Term Care". Washington, DC: National Citizens' Coalition on Nursing Home Reform.Advocate (Advocates Dedicated to Vigorous Ongoing Change of Attitudes toward the Elderly)! (1975, June). "A Better Way". Syracuse, NY: Planning and Research Committee of the Legislature of Onondaga County. 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).

In 1980 the Civil Rights of Institutionalized Persons Act was passed to protect the civil rights of, amongst others, residents of nursing homes and similar facilities.

A 1986 study organized by the Institute of Medicine found that people in nursing homes were not getting fair or adequate health care or personal treatment. The Institute of Medicine responded to the study by proposing broad and deep reforms in the regulation of nursing homes. These reforms were integrated into the Omnibus Budget Reconciliation Act of 1987 and passed as part of that law. Specifically, the Federal Nursing Home Reform Act is a part of the Omnibus Budget Reconciliation Act of 1987 which gives guidelines to regulate nursing home care in the United States. The act was intended to advance nursing home residents' rights. The Nursing Home Reform Act provides guidelines and minimal standards which nursing homes must meet. It also created a Nursing Home Residents' Bill of Rights.

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.Shankroff, J., Miller, P., Feuerberg, M. & Mortimore, E.(2000, Fall). "Health Care Financing Review", 22(1): 11-115. 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.

In Health and Hospital Corporation of Marion County v. Talevski, 599 U.S. 166 (2023), the United States Supreme Court held that the provisions of the Federal Nursing Home Reform Act (FNHRA) at issue unambiguously created rights enforceable under Section 1983 of the Ku Klux Klan Act (codified at ), and private enforcement under §1983 is compatible with the FNHRA's remedial scheme. The Supreme Court ruled that a plaintiff can file a federal civil rights claim because of violation of the Federal Nursing Home Reform Act.

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.Wickham-Searl, P. (1987). Intermediate care facilities for the mentally retarded and the problems of emerging policy. In: R.F. Antonak & J. A. Mulick, "Transitions in Mental Retardation, Volume 3: The Community Imperative Revisited." (pp. 125-145). Norwood, NJ: Ablex Publishing Co. These facilities, which resembled homes in their smaller sizes (e.g., 4–6)Conroy, J. W. (1996). The small ICF/MR program: Dimensions of quality and cost. "Mental Retardation", 34(1): 13-26. 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.Sundram, C.J., Shapiro, M.B., & Harris, J.J. (1980). "Converting Community Residences into Intermediate Care Facilities for the Mentally Retarded: Some Cautionary Notes". Albany, NY: New York State Commission on Quality Care of the Mentally Disabled.

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.Consortium of Citizens with Disabilities. "About Us". Washington, DC: Author. 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.Stand, R. (1989). Study of nursing home residents documents importance of individual choice and autonomy. "Information Exchange", p.5, St. Paul, MN: Developmental Disabilities Program.Ansello, E.F. & Eustis, N. (1992, winter). Aging and disabilities: Seeking common ground. "Generations and Aging Series". Amityville, NY: Baywood Publishing Co.Berge, G., Morrison, K. & Tropman, P. (1986). "Memo on Persons with Developmental Disabilities Residing in Nursing Homes". Madison, WI: State of Wisconsin, Department of Health and Human Services with report attachment [discussion draft].

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