A nursing home room
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A landmark report on American nursing homes issued Wednesday should serve as a “piercing wake-up call,” encouraging lawmakers to invest as they attempt to fix what a National Academies committee called an “unsustainable” system.

That’s according to LeadingAge president and CEO Katie Smith Sloan, one of several observers who said the Wednesday report from the National Academies of Sciences, Engineering, and Medicine’s Committee on the Quality of Care in Nursing Homes underscored the inability of the existing payment system to support quality care.

“As policymakers consider how to enact the report’s recommendations, they must back their actions with sufficient funding to make changes a reality,” Sloan said. “Without that, the committee’s work will be for naught.” 

The groundbreaking, 600-page study is the first time in more than 35 years that the Academies assessed the challenges faced by nursing homes. The last set of recommendations, sought by Congress, largely shaped the Nursing Home Reform Act included in the 1987 Omnibus Budget Reconciliation Act (OBRA).

While this investigation was not undertaken solely in response to COVID-19, committee members acknowledged the pandemic brought renewed attention to “long-standing shortfalls that continue to plague nursing homes,” said chair Betty Ferrell, RN, director of nursing research and education and a professor at the City of Hope Medical Center in Duarte, CA. 

Among the goals laid out by the committee are ensuring the workforce is well-prepared and appropriately compensated; creating a more rational and robust financing system; and increasing transparency and accountability of finances, operations and ownership.

Health economist R. Tamara Konetzka, Ph.D., of the University of Chicago served on the nursing home committee. She told LeadingAge members on a conference call Wednesday that the committee intentionally proposed its measures as an interconnected set of changes — and that implementing one, such as boosting staffing, without implementing another, such as financing reform, won’t work.

On workforce, the committee called for 24/7 registered nurse staffing and a full-time social worker in all nursing homes. Members also suggested leaders seek funding to research minimum and optimum staffing levels, an initiative independent of the White House’s own proposal on the topic. 

“Nursing homes themselves are probably unable to solve the short-term workforce problem,” Konetzka said. “Even if they’re mandated to just increase staffing, I think we’re all in agreement that that won’t really happen until we see this fundamental change.”

But she argued that a holistic approach to reform that addresses the macro-economics of skilled nursing would get the sector to a place “where we can pay people more, where we can invest in career ladders and retention and training, such that we have a more plentiful, also more highly trained and empowered workforce.”

More findings and recommendations  

The committee also recommended policymakers, state leaders and Congress work together to reform how long-term care is paid for by evaluating the adequacy of Medicaid payments, exploring more value-based purchasing initiatives for long-term care and moving toward a federal long-term care benefit.

On transparency, researchers recommended making facility-level data on finances, operations and ownership of all nursing homes publicly available and ensuring the ability to assess data about common owners of nursing homes. 

“Accountability of nursing homes must be strengthened with implementation of evidence-based oversight,” Sloan added, embracing the recommendations. “Our country needs an effective regulatory system; that’s achievable, if we harness the science of quality improvement, supporting and rewarding high-quality care.”

The American Health Care Association/National Center for Assisted Living said Wednesday that policymakers must first prioritize investing in “this chronically underfunded healthcare sector and support providers’ improvement on the metrics that matter for residents” in order to spark real improvements. 

“Providers are dedicated to learning from this pandemic, renewing our commitment to our seniors, and offering solutions that will improve the quality of care in our nation’s nursing homes,” AHCA/NCAL said in a statement to McKnight’s Long-Term Care News. “With the proper resources and support, we can transform our nation’s nursing homes.”

Holistic approach

All of the recommendations will require more resources, Konetzka acknowledged. 

Even adding transparency measures and funneling money more directly toward caregiving wouldn’t cover true needs today, she said, noting that the report repeatedly calls on Congress to intervene. She said additional investment will be necessary to move the system from one that targets “basic compliance” to one that pursues high-quality, person-centered care.

Konetzka also said better understanding of where Medicaid dollars go through transparency efforts is just the first step in aligning future payments to cover the cost of care.

“Even if there is a need for more transparency, we have lots of evidence that Medicaid rates are probably too low, probably across the board,” she said.

The report recommends that federal officials study Medicaid rates for adequacy and adjust them to cover the cost of care through short-term increases. But it’s the committee’s longer-run solution to getting past Medicaid that excites many, and that’s the creation of what Konetzka called “maybe another Medicare.” 

“In the long run, we really want the federal government to sponsor research that can design a system whereby we have some kind of federal long-term care benefit rather than all of these state Medicaid systems, and that federal long-term care benefit would cover not just people who impoverish themselves, but more of a widespread benefit.”

Committee chair Ferrell said Wednesday during a webinar on the report’s findings that she believes “people at all levels of health policies, government and communities understand” the committee’s recommendations.  She said members are “very, very hopeful to see this report implemented.” 

Her fellow committee member David Grabowski, Ph.D., Harvard healthcare policy expert, called the recommendations “an unprecedented opportunity.”

“I think there’s a momentum that we haven’t had previously towards this objective but the work can’t stop now,” he said during the webinar. “We need to keep moving forward with it.”