Image of Vincent Mor, Ph.D., of Brown University
Vincent Mor, Ph.D., of Brown University

Facilities that serve single types of skilled nursing patients  — and a payment system that differentiates and reimburses accordingly — would improve care for seniors and benefit providers, according to a preeminent long-term care researcher.

“We may want to think about restructuring or rethinking the notion of separating post-acute care from residential, long-term care, at least in some instances,” said Vince Mor, professor of health services, policy and practice and the Florence Pirce Grant University Professor in the Brown University School of Public Health. 

That separation was commonplace before the 1980s, when long-term care providers began adding rehabilitation services to help attract Medicare patients. But Mor believes combining long-term and post-acute care services in large, shared settings may have run its course, a viewpoint he says is supported by research into COVID-19’s rapid spread in skilled nursing facilities.

Mor has spent his career studying long-term care policies and helping design federal standards for skilled care providers; during COVID-19, he led early efforts to understand factors that contributed to disease transmission and authored studies on vaccination efforts.

During the NASL 2021 Legislative & Regulatory Conference, he questioned whether the current long-term care model is sustainable given design weaknesses revealed by the pandemic. In addition to health implications, Mor cited lost revenues, state inaction on Medicaid funding and the risk of provider bankruptcies as reasons to reconsider how the government pays for care.

“The industry is in trouble,” he said. “It needs to be invested in.”

Building from the ground up

Mor noted that facilities built in the 1960s and 1970s served residents whose lives started in the 1800s. A new generation has “different expectations, different quality standards, different policy requirements and different preferences,” he said during an April 28 presentation. “That means that nursing homes are going to have to respond in some way to that new world.”

Mor says the key to quality care for long-term care residents who need social support more than medical intervention may be in private rooms and smaller, Green House-style facilities. Their small residential groupings and staff assignments were associated with lower COVID-19 risk.

These smaller facilities would have different missions, regulatory structures and quality metrics than buildings where post-acute care is provided, Mor added. But he acknowledged that separating out residents who have medically complex needs from those who need end-of-life or long-term care for chronic care, won’t be easy unless policymakers tackle the costs of infrastructure and reimbursement.

“Someone has got to make that decision, and it’s probably a good time, in general, for the U.S. to think about retrofitting or altering the physical plant of nursing homes,” he said. “How to do that in a way that is fiscally viable in terms of the long-term caring costs is a real challenge.”

He also suggested seniors currently in assisted living (whose needs are similar to nursing home residents of the past) could be combined with traditional skilled nursing patients in a new, combined payment category.

The other side of care

Mor also envisions hospitals having more say in where and how to treat their patients after acute stays of the future. His comments come as some hospitals and major health systems are working to bring skilled nursing back into the fold post-COVID.

“Hospitals and skilled nursing facilities, at least on the post-acute care side, could have aligned interests, although, mostly because hospitals are the dominant players with most of the cash and the resources of making referrals to nursing homes, they’re often in the driver’s seat,” he said.

He suggested one way to increase rehab collaboration would be to capitate all post-acute care in a bundled, extended length of stay payment. Such a system could allow the hospital to provide its own skilled nursing care or opt for home care.

In essence, he said, consolidated acute care episodes could be reimbursed in a similar manner as to how the Centers for Medicare & Medicaid Services approached its total knee and total hip replacement demos.

“But it might result in less care for people in the nursing home setting and less resources because if hospitals get the money, they might take care of themselves first,” he said.