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The US Department of Housing and Urban Development should play a larger role in driving much-needed renovations and quality improvements in the long-term care sector, a group of industry experts maintain in the current edition of Health Affairs.

While skilled nursing providers and the federal government sometimes butt heads over issues of funding and regulation, both increasingly see the future of nursing homes moving toward private rooms and more household-oriented building arrangements. 

Private rooms and smaller communities are desirable because they increase resident privacy and they contribute to positive health outcomes, said a co-writer of the article, Rick Gamache, CEO of Aldersbridge Communities.

“There are mountains of data available showing the benefits of smaller home environments for nursing home residents, especially in preventing the spread of infectious diseases like COVID,” he told McKnight’s Long-Term Care News Tuesday. “Even just converting larger nursing homes to private rooms would be a huge improvement for dignity and quality of life.

But transitioning away from traditional nursing facilities toward this new model and design requires significant investment due to affiliated construction and renovation costs. While some states are beginning to provide incentives to create more private nursing home rooms, none have made the full necessary investments to match these high up-front costs.

The funds necessary for key renovations could be something that HUD could provide more of in the future, the group of six experts wrote Monday. They based their arguments on the work of the Moving Forward Coalition and a 2022 report from the National Academies of Sciences, Engineering, and Medicine (NASEM). 

“Many stakeholders in the nursing home sector have overlooked the potential for HUD to play a role in nursing home quality improvement and long-term care transformation,” they explained. “That needs to change, and the sooner the better.”

Pulling policy levers

HUD already provides some financial backing for nursing home projects, but it should increase that amount and lower barriers to entry for providers, the authors said.

“We are imploring HUD to play a role to encourage the positive growth that is necessary to improve nursing home life,” Gamache told McKnight’s. “HUD can guarantee capital loans to organizations that want to take steps to improve existing architecture or build anew.”

HUD has been increasingly careful about financing nursing homes in recent years, due to concerns over financial risks and transparency concerns. But driving care quality improvement — a key goal for the government agencies overseeing nursing homes — will require an up-front investment to change the status quo, the authors argued.

The authors also noted that many household-style facilities currently serve wealthier communities. More generous HUD funding could enable nursing homes in less affluent areas to change their style of building as well.

They further noted that increasing loans with the goal of improving nursing home quality in these areas would meet an existing HUD strategic plan to increase equity across its programs. This could mean that HUD investments in nursing home renovations could be increased without first needing congressional approval. 

The authors also laid out several ways to lower barriers to entry for providers making funds more easily accessible — such as reducing mortgage insurance premiums and increasing the amount that providers can borrow under the sector’s often-limited cash flow.  

One step forward

Providers should be active in pushing for changes such as those proposed in the article, its authors suggested.

“I believe if providers clamored for some of the incentives that we are talking about, the upper echelons at HUD would be more amenable to making them happen,” co-writer Marc Cohen, PhD, professor of gerontology at the University of Massachusetts Boston told McKnight’s. “Honestly, policy and administrative demands have to come from the ground up, and if this does not happen there is little incentive for change to occur.” 

Gamache acknowledged that some may be skeptical of how much impact such a suggestion could have, but he urged providers to continue seeking a wide variety of solutions to long-term care’s many challenges. 

“To a skeptical reader, I would say that we know this is a small step forward, but it is one of many the Moving Forward Coalition is proposing,” he said. “We all agree that the government must play a role in improving nursing homes, and the standard approach of more regulations, more inspections, and more fines, has not resulted in the positive change that is necessary.”

It’s important to plant these seeds of change now, he explained, noting that changing government policy is always a slow process.

“That is how our system works,” he said. “We’re talking about generational change, but we’re part of a movement to make it happen, and we’re creating momentum as we go.”

Pursuing this kind of change will be an increasingly vital endeavor for long-term care providers going forward, Cohen said.

“None of this is theoretical at all, as our population is aging and even with investments in home and community based services, there will be a growing need for the type of intensive care provided in the nursing home setting,” he explained. “Unless all agencies in the government are rowing in the same direction and trying to contribute to solving this challenge, we will indeed get nowhere. HUD has been overlooked too long as one such agency that could really help to move the needle.”

In addition to Gamache and Cohen, other members of the writing team were David Grabowski, PhD, a healthcare policy professor at Harvard University; Isaac Longobardi, director of the Moving Forward Coalition; Alice Bonner, chair of the Moving Forward Coalition; and Charles Sabatino, director of the American Bar Association Commission on Law and Aging.