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Shared Rooms Helped Fuel COVID-19 Deaths in Nursing Homes. Are a Million Private Rooms Possible?

They’ve become the gold standard for infection control and quality of life, but widespread adoption of private rooms would require radical changes.

spinner image A.G. Rhodes Cobb resident Carolyn Gibson sits for a portrait inside her room at her facility in Marietta, Georgia, USA, Monday, September 26, 2022.
Resident Carolyn Gibson in her shared bedroom at A.G. Rhodes Cobb, a not-for-profit nursing home in Marietta, Georgia.
ALYSSA POINTER

David Waters can’t wait for the $37.5 million overhaul of his nursing home, in Cobb County, Georgia, to be finished. The project will bring a new therapy garden to the campus, where he’ll be able to work on his beloved jade succulents. “It’s gonna be gorgeous,” the 67-year-old, clad in a bright tie-dye T-shirt and surgical mask to protect from COVID-19, said in a recent Zoom call.

Fellow resident Carolyn Gibson, 83, also on the call, heard that the new common areas have been designed by a residential architect to resemble living rooms. “That just sounds wonderful,” she said, nodding, her big gold earrings waving to and fro.

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But there’s one change coming to the 130-bed A.G. Rhodes senior care facility, just outside of Atlanta, that lights up residents’ eyes like no other: private rooms. When construction is finished later this year, the facility’s shared two-bedrooms will be replaced by 58 private rooms. And a brand-new building will boast 72 more private rooms for memory care patients.

Shared rooms will be relics of the past. 

“The privacy – I’d just love that,” says Gibson, who currently has a roommate. “I could turn up my television as loud as I want, put things on the walls … I would just be able to make it my own little cocoon.”

“One person per room?” says Waters, who also has a roommate. “Sign me up!” 

spinner image A.G. Rhodes Cobb resident David Waters looks at plants inside the greenhouse at the facility in Marietta, Georgia, USA, Monday, September 26, 2022.
A.G. Rhodes resident David Waters inspects plants in the facility’s current greenhouse. A new therapy garden is part of the nursing home’s reconstruction plan.
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It’s a feeling shared by many of the nation’s 1.2 million nursing home residents and their loved ones, especially after the COVID-19 pandemic. The virus has killed more than 163,000 nursing home residents, according to government data – likely an undercount. Shared rooms helped enable COVID’s wildfire-like spread through the facilities.

As a result, private rooms for residents are part of President Joe Biden’s sweeping plan to improve the nation’s 15,000 nursing homes, announced early last year. A growing body of evidence shows that private rooms not only help prevent infections from spreading, but that they also lead to better overall health and satisfaction among residents. Biden’s plan instructs the federal government to explore “ways to accelerate phasing out rooms with three or more residents and to promote single-occupancy rooms.”

But implementing such a vision could take decades, if it happens at all. Most U.S. nursing home residents currently live in shared rooms, with two to four residents and a shared bathroom. So while some nursing homes, like the nonprofit A.G. Rhodes, are helping deliver on Biden’s goal, many in the industry say widespread adoption of private rooms would require huge shifts in how facilities are configured, financed, regulated and run. Nursing home operators, resident advocates and industry experts say the federal government would need to do much more to drive a revolution in how residents are housed.

“Our nursing home model doesn’t support private rooms at all right now,” says Sheryl Zimmerman, co-director of the University of North Carolina at Chapel Hill’s Program on Aging, Disability and Long-Term Care. “Radical changes are going to have to happen if we want to see more.”

Old buildings, outdated care  

After World War II, a law known as the Hill-Burton Act transformed the nation’s senior housing from small privately run dwellings into highly medicalized facilities that resembled hospitals. The new nursing homes were regulated and largely funded by the government. And the focus, many industry experts say, shifted from welfare to health care.

As demand for senior care boomed over the following decades, thousands of large chain-operated nursing homes with hundreds of beds cropped up. Picture multi-story buildings, long hallways, lots of medical equipment, drug carts, commercial cafeterias — and shared rooms. Such facilities are still the norm today, with more than half of the nation’s current nursing homes built before 1980.

But new ideas about personalized and homey nursing home care took root in the ’80s, as resident advocates pushed for more of a balance between clinical care and quality of life. New long-term care models promoting person-centered care and home-like settings emerged.

The Green House Project, for example, was founded in the early 2000s to create “radically noninstitutional eldercare environments.” The not-for-profit has since built more than 350 homes around the country.

Each Green House “household” accommodates no more than 12 residents, and everyone gets a private bedroom and bathroom. Communal spaces add to the hominess. Picture a residential-style kitchen, an open-plan dining area with a large table, a central lounge with a fireplace and accessible outdoor spaces like porches and courtyards. Pets are welcome.

spinner image Exterior of the Green House Homes in Rhode Island
The exterior of Saint Elizabeth Green House Homes in East Greenwich, Rhode Island.
COURTESY OF THE GREEN HOUSE PROJECT.

The Green House project encourages autonomy and self-sufficiency among its residents, known as “elders.” Those qualities can be hard to find in traditional nursing homes. Elders can access the household’s pantry and housekeeping closets without having to ask permission. In traditional nursing homes, such access is often only granted to staff. Green House elders can also assist staff in planning, preparing or cooking meals. In most nursing homes, residents are barred from big commercial kitchens because they’re unsafe.

The more residential-style settings tend to yield better results than traditional nursing homes. Residents of Green Houses — the most widely studied of the smaller-house models — have lower rates of rehospitalization, are 45 percent less likely to need catheters and are 16 percent less likely to be bedridden. Other studies show higher quality of life, lower medical costs and reduced staff turnover.

COVID-19 outcomes are also better. Larger facility size is significantly related to the increased probability of COVID‐19 cases. Infection rates in nursing homes with 50 or more residents were nine times higher than the rates in Green House nursing homes, one study found. It reported that lower rates were likely due to residents having private rooms and to the fact that fewer people live and work in Green Houses than in traditional nursing homes.

AARP has supported efforts to increase the availability of small-house nursing homes. “We know that residents prefer to have their own rooms and privacy in a more home-like environment, and these settings provide that,” says Rhonda Richards, a government affairs director for the organization who specializes in long-term care. “They also offer residents improved infection control, which, as the pandemic showed us, is very important.”

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Growing interest, little change

Despite praise and growing scientific validation for smaller nursing homes with private rooms, they’ve been slow to spread.

Interest in the Green House Project skyrocketed during the peak of the pandemic, says Alex Spanko, the organization’s communications director. But only about 4,100 residents nationwide — less than 1 percent of the U.S. nursing home population — currently live in a Green House household. “Interest is still not really translating into firm action,” Spanko says.

The U.S. Department of Veterans Affairs changed its nursing home design approach to promote small-house homes in 2011. A VA program that funds 65 percent of a construction project for a state-owned Veterans Home has helped create 4,400 more private rooms for veterans.  

There’s been a “big push” for states to move towards smaller-home models, says the VA’s Anna Gaug, who manages the program. “We want veterans to feel at home,” she says. “They deserve to have privacy, dignity and to feel pride in where they’re living as they’re aging.”

However, the majority of the 18,000 veterans in State Veterans Homes are still in shared rooms.

Lawmakers have introduced bills in Congress to boost the small-house and private room movement. The Nursing Home Improvement and Accountability Act of 2021, for example, would fund $1.3 billion worth of infrastructure developments or modifications that are in line with small-house models in some nursing homes. Those would serve as demonstration projects to evaluate the impact.

A separate bill known as the IMPROVE Nursing Homes Act would give grants to convert traditional nursing homes into small-home facilities, bringing small-home care to 250,000 more residents by the end of the decade.

For now, though, private rooms remain the rare exception in nursing homes. The White House, in rolling out its nursing homes improvement plan last year, called shared rooms “the default option.”

The high cost of rebuilding

A.G. Rhodes’ campus outside Atlanta was constructed in the early 1990s, in the style of other hospital-like nursing homes of the time. But in 2016, after partnering with a nonprofit that coaches nursing homes toward more personalized care, the organization realized its Cobb building wasn’t conducive to the new approach. “While it worked for a certain time in history,” says A.G. Rhodes CEO Deke Cateau, it had become “archaic.”

That became more apparent with the COVID-19 pandemic. Among A.G. Rhodes’ three Atlanta-area campuses, the Cobb campus, with the fewest private rooms, suffered the most virus deaths: 14, roughly twice as many as the other locations.

National data from the time showed that people with dementia — which afflicts 80 percent of A.G. Rhodes’ residents — were twice as likely to get COVID-19 than those without it. And they were more than four times as likely to die from it. “We just fundamentally needed to have different infrastructure in order to make a difference,” Cateau says.

The move to private rooms came at a huge cost: $37.5 million. The nonprofit accepts mostly low-income Medicaid-insured residents, who tend to be less lucrative for nursing homes than residents on Medicare or who pay privately, so community support was vital. Donations provided $7.5 million and the project qualified for $6.5 million in federal tax credits for projects in low-income communities.

A $24 million loan covered the rest, but it was hard to secure, Cateau says. Nursing home occupancy rates dropped dramatically during the pandemic, from 86 percent in early 2020 to 72 percent in early 2021. It’s rebounded some, but investors remain wary.

Other facilities say they can’t afford the shift to private rooms. Fifteen years ago, White Oak Management, Inc., a for-profit long-term care provider operating 15 nursing homes across the Carolinas, started converting some shared dorms to private ones. After a decade, it had managed to move roughly a fifth of its skilled nursing beds into private rooms. Then progress halted.

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“It got expensive,” says John Barber, executive vice president and chief financial officer. “We did all we could with the resources we had.”   

White Oak wants to get back to converting more rooms to private ones, but Barber says he can’t without outside money: “Maybe a low interest loan from the government to do the construction.”

Limping toward private rooms

Medicaid, the federal-state health insurance program for low-income people, is the biggest funder of nursing home care in the U.S., footing somewhere between 45 and 65 percent of the country’s yearly nursing home bill. Historically, though, the program has only paid for nursing home stays if residents are in shared rooms, unless a private room is deemed medically necessary. More private rooms have generally meant less government funding.    

Nonetheless, Cateau decided all the rooms at A.G Rhodes’ Cobb campus would be private. A “moral imperative” is driving the switch, he says. But he’s also taking a leap of faith, hoping that governments will change their funding models for nursing homes. “The reality is we’re going to have to get help federally or locally to support this,” he says.

Most providers won’t take that risk. Fewer than a quarter of U.S. nursing homes today are nonprofits like A.G. Rhodes. About 70 percent are for-profit businesses, and more than half are operated by corporate chains. Private equity firms, whose business depends on short-term profits, own a growing share.“We have a for-profit health care system, for better or worse,” says the Green House Project’s Spanko. “As long as something is profitable, the industry’s not really going to make a big shift to fix it.”

But in a move last summer, the federal Centers for Medicare & Medicaid Services (CMS) told states, which set Medicaid payment rates, that they can change their longstanding practice of not funding private-room stays. Instead, the CMS suggested that states set higher payment rates for Medicaid residents in private rooms. So far, though, there’s no requirement for states to follow this guidance – it’s optional.  

Which means it’s unlikely that private rooms will become the norm, says Charlene Harrington, a professor emeritus of sociology and long-time nursing home researcher at the University of California, San Francisco. “State Medicaid budgets are usually tight,” she says, “so they don’t want to raise the rates any more than they have to.”

Instead, says Harrington, the federal government should require that nursing homes provide private rooms in order to receive Medicare and Medicaid dollars, which are a huge source of their revenue. With occupancy rates at record lows, leaving many shared rooms unfilled, now’s a good time for homes to start the transition, she argues.

While the White House’s 2022 nursing home plan encourages more private rooms, it so far lacks specific strategies for getting there, apart from the summer guidance on Medicaid payments. The plan has “no teeth,” says Zimmerman of the University of North Carolina at Chapel Hill.

When asked if the federal government has forthcoming plans to reduce overcrowding, the CMS wrote in an email to AARP that it “does not speculate on future agency action.”

‘Private rooms are really just step one’

Private rooms alone won’t remedy nursing home system’s shortcomings. “The Green House model is a lot more than just the building,” says Spanko. “It’s about the culture, too.”

For example, moving residents into private rooms without investing in communal spaces or activity programs or more staff that bring them out of those rooms could cause increased loneliness and social isolation, an issue nursing homes really struggled with during the pandemic.

“Private rooms are really just step one,” says Spanko. “There’s another 25 steps that also need to be done to get to where we really want to be.”

Another worry is that by turning shared rooms into private rooms, facilities may have to decrease their total number of beds, limiting their ability to serve the country’s exploding population of older adults. The number of adults age 85 and older is projected to reach 19 million in 2060, up from 6.4 million in 2016.

But the U.S. needs better alternatives to institutionalized nursing home care, argues AARP’s Nancy LeaMond, chief advocacy and engagement officer. “We absolutely must address the safety issues in nursing homes. But that’s not the whole job,” she wrote in a blog post on long-term care reform. “We should also consider providing more of the supports and services that enable people to live at home — and when that is not possible, to live in environments where they will thrive.”

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