By Thomas Goldsmith
“Ineffective, inefficient, fragmented, and unsustainable.”
That’s the summation of the state of U.S. nursing homes — their practices, oversight and funding — that appears in a sweeping report from an expert committee of the National Academies of Science, Engineering and Medicine.
Members of the committee compared the new report, “The National Imperative to Improve Nursing Home Quality,” published in April, with a landmark 1986 publication by the related Institute of Medicine, “Improving the Quality of Care in Nursing Homes.” The earlier paper highlighted many problems with the nursing-home system, including resident neglect, poor health-care quality, and inadequate regulation. Many of those critiques resulted in significant changes in federal policy in the 1987 Omnibus Budget Reconciliation Act.
Dr. Philip Sloane, a professor of family medicine and geriatrics at the University of North Carolina School of Medicine, said his willingness to serve on the committee rested on the impact of the previous report. Each of the enlisted national experts — from the fields of nursing, veterans affairs, health economics, family medicine, geriatrics, health care policy, vaccines, public health and cancer research — gave a stamp of approval to each of the panel’s far-reaching conclusions.
“There was a big push for a little more professional professionalism — RNs, real social workers,” Sloane said in a phone interview. “In terms of just a physical plant, there is an encouragement to have smaller settings, single rooms, private rooms. Those have all been shown to enhance both health and life, and satisfaction.”
Renate Carreras, 77, a Raleigh retiree, says her image of nursing home care has been colored by her pre-COVID stay in a North Raleigh facility in 2018. Like many residents, she entered a nursing home for rehab after surgery, the kind of short-term stay covered by Medicare, the government insurance program that covers adults over 65, as well as some people with disabilities.
“In the beginning, I really needed help and I wouldn’t get it,” Carreras said. “The other people will yell and scream because they couldn’t get attention. If it’s the middle of the night and you need to get a diaper change and nobody shows, it’s awful.
“But I got better, I could change for myself.”
The report takes pains to point out that countless facilities and professionals provide excellent care under trying circumstances: “The committee also recognized the many examples of outstanding care being provided in nursing homes and realized that across the United States nursing home staff representing all disciplines are each day providing wonderful care to residents who they consider as beloved family members,” committee chair Betty Ferrell wrote in a preface.
“Sadly, these staff have put their own lives at risk and are often not well trained, supported, or compensated.”
‘Nursing homes have been really invisible’
Ferrell, a professor and director of nursing research and education at the City of Hope National Medical Center, in Duarte, California, addresses an overarching need for a broad U.S. population to consider the needs of people in long-term care.
The general level of understanding rose somewhat with the onset of the pandemic, she said.
“Because of COVID, especially in those early months, it’s right there in our faces,” Ferrell said in an interview with NC Health News. “‘Here’s another picture of people being taken out of nursing homes on stretchers.’”
“COVID has lifted the veil on nursing homes. COVID has made nursing homes live in people’s consciousness.”
Among key points, the committee says a crisis remains in hiring enough direct-care workers, in nursing homes as well as in many service-oriented sectors. The shortages can be attributed to low-level compensation, a lack of consistent training and resulting scarcity of opportunities to move up a career ladder.
Watch the funding flow
In North Carolina, the state of nursing-home care will be closely linked to Medicaid funding in the state budget under discussion at the General Assembly. Even though Medicare covers the costs of doctor visits, hospitalization and pharmaceuticals for the overwhelming majority of older adults, the program only covers nursing home care for short stays such as rehabilitation after surgery or, say, a stroke.
When it comes to long-term care, Medicaid becomes the dominant payer for many people who are low income, or who have exhausted their retirement savings.
Kody Kinsley, secretary of the NC Department of Health and Human Services, cites as a goal keeping the Medicaid nursing home allocation at the increased levels at which it was funded during the pandemic.
“We’ve got to stabilize rates and support people and try to get these facilities more supported in a variety of ways,” Kinsley told NC Health News. “We also need to try to help on the pipeline process of actually getting and keeping the staff, and reducing the turnover.”
Some of the committee’s ideas discussed for improving care seem likely to raise eyebrows, at least on the part of the industry, with a U.S. market value projected to near $600 billion in five years. One is to allow the federal Centers for Medicare and Medicaid Services to gain access to the business tax returns of nursing-home providers. Another would give funds to innovators in long-term care to get their projects off the ground.
“Maybe they’ve given each person a budget so they can have a few thousand dollars,” Sloane said. “So if they need to or want to buy something that will help enhance life for some residents, they just don’t have to go up the chain to do it.”
Looking for immediate change
Overall, the report makes the case that nursing home care has consistently failed to meet the needs of residents and that immediate change is necessary. Citing the 1986 report, members found that many of the subsequent regulations have not been followed comprehensively, to the harm of residents.
“Those same shortcomings rendered nursing homes, their residents, and staff extremely vulnerable and unprepared to respond to the public health emergency,” of the pandemic, the committee said.
Overall, the report’s authors cited an extensive history of inadequate funding in the nursing home sector, amounts that fail to incentivize providers to offer residents the best care. The system should also ensure that owners are making the best use of the billions in tax-dollar payments, as well as private-pay fees.
“First of all, there’s tremendous distancing between ownership and responsibility for day-to-day care,” said Sloane, the UNC doctor and professor. “And so if you’ve got an owner who’s been mainly interested in the property, in this investment, and they never walk in the building, they may never see a resident.
“It’s easy for them to make financial decisions. They may not be necessarily good for residents, because they’re so distant from the impact of their decision.”
That distance between owners and those being cared for is a concern for state Rep. Donna White (R-Clayton), among the state legislators most involved in aging matters.
“I’ve heard from lots of constituents across the state, that that is certainly an issue, that there doesn’t seem to be responsibility from owners,” White said at the General Assembly. “And the staff is not aware sometimes of who actually is the owner and is kind of out there on their own.”
Adam Sholar, president of the nursing home trade group North Carolina Health Care Facilities Association, emphasized the role of funding levels and the direct-care-worker shortage in improving nursing-home care.
“The nursing home industry in North Carolina and across the nation continues to suffer from a significant lack of resources and a severe shortage of workers, Sholar said. “If we want to lift up long-term care in this country, and we must, then lawmakers should first and foremost work to provide more resources and help us grow our workforce.”
The report also calls for any increased or new government funding to be accompanied by strong requirements for transparency to make sure that the money gets into the hands of people doing the frontline work, and that it doesn’t go directly to lining the pockets of owners.
Not to worry, Kinsley said.
“Right now, the labor market is really taking care of that for us,” he said. “They can’t keep staff and the demands of staff are so high. The forcing function to pay staff sufficiently is huge.”
Bumps in pay for nursing home employees, as well as for teachers and those in other helping sectors, is likely to appear in the state budget under consideration in the ongoing short session of the state legislature, House of Representatives Speaker Tim Moore (R-Kings Mountain) told reporters last week at the General Assembly.
“Because we’re a growing state, with the baby boomers aging, and those of us who are now aging, who are behind the baby boomers, we know that more and more folks are going to need to be in health care,” Moore said. “And we’ve got to ensure that that pipeline continues to get those folks there. So that’s something that in this budget that we have really leaned into, in a major way.”
Private equity mulled
Ownership of facilities also gets significant attention in the report, including the quick growth of purchases by private equity interests, or groups of private investors out to get large returns from far-reaching buys.
In a separate study published in November in the New England Journal of Medicine, researchers compared the health of residents of nursing homes purchased by private equity companies to those in a set of other facilities run for profit. Residents of the private equity-owned homes incurred higher costs and faced more frequent emergency-department visits and hospital stays for ambulatory-care-sensitive conditions.
Conditions designated ambulatory-care sensitive are “those conditions for which hospital admission could be prevented by interventions in primary care.”
However, the national industry group American Health Care Facilities Association says critics should take into consideration the growing reach of private equity into many business sectors. North Carolina nursing home operators are represented by the related North Carolina Health Care Facilities Association. The federal Government Accountability Office is pursuing an investigation of nursing-home ownership by private equity groups, Kaiser Health News reported.
“The focus on private equity ownership of nursing homes is a red herring,” Mark Parkinson, AHCA president, said in a statement provided to North Carolina Health News. “If policymakers want to talk about private equity, then this is a conversation for the entire healthcare system, not just nursing homes.”
Maintain equitable treatment, report says
In a note of caution, the report advises planners to take every pain to avoid worsening patterns of unequal provision of care and resources. Such disparities happen too often, members say, affecting nursing-home residents on the basis of race and ethnicity.
Among her diverse neighbors in an affordable housing building near downtown, nursing homes often get a bad rap, said retiree Carreras, a native of Germany.
“They say that is not a place I would like to stay,” she said in a telephone interview.
Rose Hoban contributed reporting for this article.
Experts who produced “The National Imperative to Improve Nursing Home Quality”
In addition to Ferrell and Sloane, members of the committee that compiled the 600-page nursing home report included:
Mary Ersek, senior scientist at the U.S. Department of Veterans Affairs;
Colleen Galambos, chair in applied gerontology and professor, University of Wisconsin–Milwaukee;
David Grabowski, professor of health care policy, Harvard University;
Kathy Greenlee, Obama-era U.S. assistant secretary of aging;
R. Tamara Konetzka, professor of public health sciences, University of Chicago;
Christine A. Mueller, professor, University of Minnesota School of Nursing;
Marilyn J. Rantz, professor emerita, University of Missouri Sinclair School of Nursing;
William Scanlon, former managing director of health-care issues at the former U.S. General Accounting Office until 2004, and consultant, West Health Institute;
Debra Saliba, director Borun Center and professor of medicine, University of California, Los Angeles;
David G. Stevenson, professor of health policy, Vanderbilt University School of Medicine,
Jasmine L. Travers, assistant professor, Rory Meyers College of Nursing, New York University; Reginald Tucker-Seeley, vice president, health equity, at the nonprofit ZERO-The End of Prostate Cancer;
Edward L. Schneider, assistant professor of gerontology, Leonard Davis School of Gerontology, University of Southern California;
Rachel Werner, executive director, Leonard Davis Institute of Health Economics and professor of medicine, University of Pennsylvania.