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April 8, 2022

Nursing home care in America is broken. Will there be any change?

Daily Briefing

    Shortcomings of the U.S. nursing home system, including inadequate care and staffing, risk the health and safety of millions of residents, according to a new report from the National Academies of Sciences, Engineering, and Medicine (NASEM).

    Infographic: Caring for an aging population

    Report details and key findings

    In the report, a 17-member committee assembled by NASEM concluded that "[t]he way in which the United States finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, fragmented, and unsustainable."  

    In response, the committee issued a set of recommendations to improve nursing home care in the United States. And while committee chair Betty Ferrell said the report "could profoundly change the delivery of care," the committee acknowledged that the recommendations represent an ambitious combination of both short- and long-term goals that would require the coordination of government agencies, providers, and many others in the industry.

    "I will stress that this is a comprehensive package of reforms. Many stakeholders will want to grab their preferred recommendations and ignore the ones that are more challenging," said David Grabowski, committee member and Harvard University health care policy expert. "That is a mistake. We can't nibble around the edges and expect transformative change."

    Notably, the committee highlighted the underinvestment of the nursing home sector that has been consistent "for decades" and noted that the implementation of their recommendations would likely require "a significant investment of financial resources at the federal and state levels," and from providers. 

    "This report is a piercing wake-up call for policymakers," said LeadingAge President and CEO Katie Smith Sloan. "Decades of underfunding have left America's nursing home system in desperate need of an overhaul."

    7 recommendations to improve the U.S. nursing home system

    To create a more adequate approach to nursing home care, the committee made recommendations across seven key themes.

    1. Provide comprehensive, equitable, patient-centered care

    According to the report, nursing homes should implement improved care models that ensure the health, quality of life, and safety of residents while promoting autonomy and managing risk. In addition, residents' and families' preferences, goals, and values in care planning should be prioritized to help improve residents' quality of life. The report also recommended stronger emergency preparedness for nursing homes around the country.

    2. Ensure workers are well-trained and appropriately compensated

    The committee recommended competitive wages and benefits, higher minimum staffing standards, and expanded training requirements that include diversity, equity, and inclusion training.

    3. Encourage transparency and accountability of finances, operations, and ownership

    To increase financial transparency and accountability, the committee recommended U.S. lawmakers collect, audit, and publish detailed facility-level data that discloses the finances, operations, and ownership of all nursing homes within an accessible real-time database.

    4. Establish a rational and robust financing system

    The committee suggested a strategy to transition to a federal long-term care benefit that would provide sufficient financial coverage for comprehensive nursing home care services.

    5. Create a highly effective quality assurance system

    The committee suggested giving state survey agencies adequate resources to allow them to increase oversight of state survey performance and evaluate strategies to improve quality assurance initiatives.

    6. Grow and enhance quality improvement programs

    According to the committee, quality measures that report resident and family experience and gauge what they want from nursing homes need to be developed and regularly reported.

    7. Implement health information technology across all nursing home facilities

    The committee suggested using financial incentives to support the adoption of health information technology in all nursing homes—a move that could contribute to improvements in care delivery and coordination, enhanced staff productivity, increased promotion of patient safety, and reduced health disparities. (Christ, Modern Healthcare, 4/6; Grabowski et al., STAT News, 4/6; Brown, McKnights Long-Term Care News, 4/6; Sedensky, AP/ABC News, 4/6)


    Advisory Board's take

    Nursing home care needs a rehaul—but will changes actually happen?

    By Miriam Sznycer-Taub and Monica Westhead

    There is no question that there are fundamental problems with nursing homes, many of which are clearly stated in this report. And we certainly agree that implementing many of the report's recommendations would go a long way in improving the care and quality of life for both nursing home residents and the nursing home workforce.

    However, we remain skeptical that these changes will actually be employed.

    The nursing home sector has been largely ignored and under-invested in for many years and it will require large investments by all stakeholders to remedy this. Many of these recommendations seem to hinge on the creation of a federal long-term care benefit that would allow for adequate financing of care in nursing homes. Without this, we worry that many of these changes will simply add additional burdens on nursing homes to increase staffing levels, pay their workforce more, or invest in additional technology without support or changes to reimbursement. And that could lead some nursing homes to close down, which would limit access—especially for seniors with fewer resources while the population of seniors is increasing.

    Reading this report also reminded us that these challenges are not just confined to nursing homes but reflect broader concerns with the way our health care system is (or is not) set up to care for the growing population of seniors. The current system is highly fragmented—requiring seniors and their family caregivers to navigate the differences between traditional Medicare, Medicare Advantage, and Medicaid.

    This has led to an imbalance in investment where the industry has overinvested in some areas, like strengthening Medicare Advantage and focusing on technological supports for "younger seniors" to age in place. And we've seen less investment in other areas including behavioral health care for seniors, and accessible long-term care for those who need it. As the population gets steadily older, we'll need to rethink all aspects of how we provide medical and residential care for older adults.

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