It's complicated. This phrase has become the default and arguably lazy response to many 21st-century challenges. But when it comes to finding ways to reform and improve America's nursing homes, it is sadly accurate.
The roots of the long-term care industry's problems are deeply tangled, as we reported in the December issue of the AARP Bulletin. The institutions that serve so many older and infirm Americans were created based on rules and laws passed decades ago, when needs and expectations were different. Nursing home funding and oversight come in large part from government budgets that can be stingy. But most nursing homes are privately owned, meaning there is little transparency into their finances and operations. Are they, as they claim, pinching pennies to survive, or are they profiting at the expense of quality care?
As the past 10 months have revealed, such a fraught arrangement couldn't withstand the pressure test of COVID-19; more than 133,000 residents and workers have died due to the coronavirus, representing about 40 percent of total U.S. pandemic fatalities.
"The current system for funding and delivering long-term care services is a national crisis that we have to address,” says Bob Kramer, cofounder and strategic adviser for the National Investment Center for Seniors Housing & Care. But how? The AARP Bulletin spoke with more than three dozen experts. What follows are 10 ways they say America's long-term care industry can evolve to be healthier and more stable in the short term, and ultimately more inviting and responsive to the people who need to reside there.
Goal: Make Environments Healthier
1. Require more registered nurses
Nursing homes with higher staffing levels of registered nurses (RNs) did better at controlling the coronavirus and reducing death, research from early in the pandemic shows. In a study looking at COVID cases in March and April among 215 Connecticut facilities, for those that had at least one positive case, every additional 20 minutes of RN coverage correlated to a 22 percent decline in cases, according to researchers at the University of Rochester Medical Center. A study in California reached similar conclusions. But federal laws and regulations only require nursing homes to employ an RN for eight consecutive hours a day. That can leave 16 hours with no RN coverage. Federal law also allows states to grant waivers to nursing homes that can't meet the regulations.
Regulations for RN staffing were put in place as part of the Nursing Home Reform Act of 1987, in response to a congressional study that found that many older Americans were receiving poor medical attention in long-term care and that some suffered from neglect and abuse. Richard Mollot, executive director of the Long Term Care Community Coalition, says the pandemic has exposed even more problems than that study did, so he is hopeful that lawmakers will be inspired to new action.
2. Partner with hospitals
During the pandemic, hospitals in Maryland began working with nursing homes, providing testing and expertise on infection control and use of PPE, says Morgan Katz, M.D., an infectious diseases expert at Johns Hopkins University. The partnership helped prevent major outbreaks in nursing homes that could overwhelm emergency rooms. “We needed to figure out what we could do to keep them out of the hospital,” Katz says.
Laurie Archbald-Pannone, M.D., a geriatrician and associate professor at the University of Virginia School of Medicine, ran a similar program in her state, sending rapid-response teams to assess outbreaks and assist care workers with infection control. It also provided telemedicine services. Nursing homes in the program have experienced lower rates of mortality and hospitalization than the national average, Archbald-Pannone says. “Our health care system as a whole tends to be fragmented. We have learned some lessons that are not just COVID-specific and that we can use going forward."
3. Improve infection control
"Nursing homes are like a tinderbox,” says Joseph Ouslander, M.D., professor of geriatric medicine at Florida Atlantic University. “It only takes one person to start a fire that could cause many deaths.” Among the reasons: Nursing home residents often have weakened immune systems due both to age and chronic disease, residents often share rooms that have them living within feet of each other, and staff members flow in and out.