Michael Wasserman, M.D.

I am regularly described as “a critic of the nursing home industry.” A nursing home chain executive once admonished me for using the term nursing home industry. He told me that I should call it the nursing home profession

The COVID-19 pandemic led to 169,291 more nursing home resident deaths in 2020 alone and has painfully reminded me of the difference between the two terms. I am a critic of the nursing home industry. I am not a critic of the nursing home profession. It’s time to set the record straight.

The people who work in nursing homes are some of the most dedicated, caring and compassionate human beings I have ever worked with. This includes administrators and directors of nursing, and most certainly reflects the daily work of the front-line staff. I often hear the question, “Who would want to work in a nursing home? They are horrible places.” People who say that haven’t spent time with the people who work and reside in nursing homes, or they would know better. So, why am I a critic of the nursing home industry?

If one wanted to approximate the structure and function of a nursing home, including all of the direct care time, in an individual’s home, it would cost more than $20,000 a month. Few can afford this. Even if one could manage to provide the necessary services for a frail older adult to live safely at home, the issue of social isolation is still significant. I have often compared nursing home life to that of college students living in a dormitory. The residents have roommates, eat in a dining hall and participate in daily activities. 

Nursing homes do not have to feel institutional, nor do they have to lack in adequate care. They already benefit from incredible, dedicated caregivers. We must ensure that these caregivers exist in sufficient numbers, are treated with respect, and are paid a living wage. There will always be a need for nursing homes, all talk of “hospital-at-home” and such models aside. The issue comes down to how the industry, as a business entity, is structured. Which brings me back to the difference between the nursing home industry and the nursing home profession

The nursing home industry is composed of different asset-bearing businesses. The first and foremost is real estate. It has become the norm that nursing home real estate assets are held separately from the operations. This allows real estate owners to claim no role or responsibility for the quality of care delivered in nursing homes. It also takes the largest leverageable asset out of the financial equation in relation to day-to-day operations. The nursing home industry is primarily about real estate. 

There is also a myriad of services, including housekeeping, therapy and even staffing, that exist as separately held businesses. These businesses earn their own profits, but being separate from the nursing home operation itself, creates silos that make it hard to focus all reasonable financial resources on the delivery of care in a nursing home. 

Nursing homes also commonly engage management companies. These companies often oversee the financial and administrative aspects of the nursing home. They may also provide clinical consultative services. Once again, these companies are separate entities, earning their own profits. 

The byzantine structure of the nursing home industry leaves operational entities — the homes themselves — lacking assets and resources. Nursing home industry leaders often complain that nursing homes don’t make money. They are factually correct. 

However, what they neglect to share is that the nursing home industry as a whole actually does quite well financially, which is why I accept the description of being a critic of the nursing home industry. At the same time, I’m proud to be a member of the nursing home profession. Nurses, nursing assistants, housekeepers, social workers, medical directors, attending physicians, nurse practitioners, administrators, directors of nursing, to name some of the individuals who work in nursing homes, care deeply about the residents who live there.

Many of my colleagues complain that there aren’t more stories about the amazing people who work in nursing homes. I agree. Unfortunately, positive stories about compassionate people who care for vulnerable older adults don’t sell a lot of newspapers or get a lot of internet views. 

More to the point, there are countless stories about less-than-ideal care for nursing home residents. These stories must be told, but they must be associated with the structural weaknesses inherent in an industry that by its very makeup doesn’t effectively utilize the money that should be spent on the actual care provided in nursing homes. 

The nursing home industry as a business is doing what businesses do. They attempt to maximize profit. Maintaining the same structure that pulls assets and resources out of the care delivery model will only continue to make me and other advocates critics of the industry

Perhaps taking a cue from the nursing home chain executive who talked to me about the nursing home profession is the key to the future. Let’s start by focusing our attention on all of the positive aspects of nursing homes and the care that they deliver. Use this information to restructure the way nursing homes are set up as business entities. 

It’s time that nursing homes be about the delivery of care to the vulnerable people who live inside them, and not about real estate and other ancillary businesses. Only then can we call the entire entity the nursing home profession.

Michael Wasserman, M.D., is a geriatrician and past president of the California Association for Long Term Care Medicine.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.