McKnight's Long-Term Care News, December 2018, Resident Care, David Grabowski

Because of the devastation COVID-19 has wrought on nursing homes, regulatory changes likely are coming, according to a highly respected long-term care researcher.

“I think we’re going to see some big, big changes going forward,” said David Grabowski, Ph.D., a professor of healthcare policy at Harvard Medical School. He was the opening day keynote speaker Friday for the virtual conference of the National Association for the Support of Long Term Care (NASL).

The plethora of pandemic-related problems — among them, the exorbitant number of resident and staff deaths, resident loneliness due to shutdowns, and low occupancy rates and hospital admission rates — has revealed underlying systemic problems, Grabowski said. These include: low Medicaid payments, inadequate pay for staffing, an ineffective regulatory model, lack of quality transparency and fragmented ownership structures.

“COVID-19 has revealed the fragility of nursing homes’ business model and our underinvestment in high-quality long-term care,” said Grabowski. He served on the Coronavirus Commission for Safety and Quality in Nursing Homes, which released a report in September that provided 27 recommendations and over 100 action steps for the Centers for Medicare & Medicaid Services. The report analyzed areas ranging from testing to access to visitation to aging nursing homes’ infrastructure.

In the long run, the goal is to reimagine nursing homes, he said Friday, noting that there likely will be a shift away from nursing homes to home- and community-based care settings.

Among the changes he’d like to see are smaller nursing home settings, such as the Green House model of care, which has endured fewer deaths from the pandemic. He also noted, however, that such a model has implementation challenges.

Grabowski provided other steps that could strengthen U.S. nursing homes in the post-pandemic world:

•  Realign Medicare and Medicaid payments to approximate costs

•  Encourage policies that increase the number of clinicians on-site

•  Ensure payments flow to direct caregivers via wage floors and wage pass-throughs

•  Establish minimum nurse and nurse aide staffing standards

•  Increase quality transparency

•  Enable better enforcement and quality improvement through regulatory reform

•  Invest in Medicaid home-and community-based services

•  Establish a public long-term care benefit

Alternative pay models

During the question-and-answer portion of the presentation, Grabowski noted that some alternative payment models are promising. Institutional special needs plans (I-SNP), for example, emphasize more clinical care and pay nursing homes to provide this higher-quality care.

“It’s almost a win-win,” he said.

Grabowski, who recently co-authored a study on the potential benefits of bundled payments for nursing homes, also sees positive aspects of this model for nursing homes.

“I really like models that engage nursing homes and don’t pull dollars out,” he said.

Testing misstep

During the presentation, Grabowski talked about the government’s nursing home testing misstep. While its rollout of rapid antigen testing instruments to nursing homes over the summer was initially encouraging, it has not been a game-changer because of concerns about accuracy, whether staff know how to use them, and how nursing homes will have to pay for testing supplies going forward.

“This should have been our priority from the beginning and I believe we were slow here,” he said.

Even at the end of September, less than 17% of facilities were averaging test results returns in less than a day, he said.

“We need testing in less than a day if this is really going to be effective,” he said.

Staffing impact

One of the biggest problems the pandemic has revealed is the lack of investment in staff, from poor pay to lack of personal protective equipment and testing, he said. Nursing homes need to provide hazard pay, a living wage and non-punitive sick leave to staff, among other benefits.

He noted that the death count among staff has surpassed that of logging workers and commercial fishermen — the two most dangerous professions in the United States before the pandemic. Now, with more than 1,000 staff deaths in nursing homes, the caregiver is “the most dangerous job in America,” he said.