Nurse takes care of a bedridden and sick nursing home resident
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A long-awaited national report has found that the way the United States finances, delivers and regulates nursing home care is ineffective and unsustainable. Immediate action is needed to bring meaningful changes to the system to better meet the needs of residents and staff, the vast team of researchers added. 

The findings were released Wednesday morning by the National Academies of Sciences, Engineering, and Medicine’s Committee on the Quality of Care in Nursing Homes. A report sponsor called the landmark study and action plans “a new moment in history.”

“The way in which the United States finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, fragmented, and unsustainable,” Committee Chairwoman Betty Ferrell wrote in the report.  She said the report “could profoundly change the delivery of care.”

Committee members also acknowledge, however, that the 605-page analysis and set of recommendations is a vast, ambitious mix of short- and long-term goals that would require the cooperation of government agencies, providers and many others —  as well as the ceding of some authority by Congress itself — to bring key changes.

The report’s overarching goal is to make high-quality, person-centered and equitable care “a reality” for nursing home residents and to provide support for staff in order to achieve it. 

Additional goals laid out by the committee included 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.

Recommendations laid out under those goals included: federal health officials implementing requirements for higher 24/7 nurse staffing and a full-time social worker in all nursing homes and fund research on minimum and optimum staffing levels, and making facility-level data on finances, operations and ownership of all nursing homes publicly available. 

The committee also honed in on the underinvestment of the nursing home sector that has suffered from “for decades” and noted that implementing these recommendations will likely require “a significant investment of financial resources at the federal and state levels,” as well as by providers. 

“I will stress that this is a comprehensive package of reforms. Many stakeholders will want to grab their preferred recommendations and ignore the ones that are more challenging,” David Grabowski, Ph.D., committee member and Harvard healthcare policy expert, told McKnight’s Long-Term Care News on Wednesday. “That is a mistake. We can’t nibble around the edges and expect transformative change.”

Responding on behalf of the provider community, LeadingAge President and CEO Katie Smith Sloan called the report validation of operator complaints about oversight and lagging support for the sector.

“This report is a piercing wake-up call for policymakers,” she said in a statement. “Decades of underfunding have left America’s nursing home system in desperate need of an overhaul.

“[A]s the commission notes, our country’s system of financing, oversight and support for nursing homes is ‘ineffective, inefficient, fragmented, and unsustainable,” she added. 

As Grabowski indicated, however, the report takes aim at a wide range of long-term care stakeholders, including providers. Coming on the heels of President Biden’s recently announced nursing home reform plans, it will undoubtedly add pressure to previous calls for more provider scrutiny.

‘Urgency is clear’

What’s promising about the report is how comprehensive and detailed it is in laying out the actions needed and by whom, said Terry Fulmer, Ph.D., president of the John A. Hartford Foundation, one of the study’s sponsors. 

Fulmer said legislators on both sides of the aisle, regulators, state policymakers and nursing home operators should all back this report and its actionable recommendations. 

“The recommendations are an interrelated and complete set that gives us the blueprint for transformative change that is desperately needed for our nursing home staff and residents,” Fulmer told McKnight’s.

But there is worry that some of the recommendations could be ignored by policymakers with the power to pursue them, a criticism that followed the release of the Coronavirus Commission for Safety and Quality in Nursing Homes’ recommendations.

“There is always a concern given the multiple agendas going on in Congress, however, the urgency here is clear,” Fulmer said. “This is a new moment in history.”

The committee also laid out a timeline for prioritizing recommendations for immediate, short-term, intermediate-term and long-term implementation. 

Immediate and short-term actions include enhancing minimum staffing requirements for nursing homes and competitive wages for workers, while long-term actions include constructing smaller facilities or smaller units within larger facilities. 

The committee said its recommendations are founded on seven main conclusions that were arrived at after speaking with dozens of nursing home stakeholders. While providers were not represented on the committee, certain leaders were consulted, along with consumers, labor leaders and dozens of others, during the research phase.

Conclusions included the observations that the system is broken and immediate changes are needed. There must be a shared commitment to improve care and changes must help improve the allocation of care and resources among certain all demographic groups. In addition, the researchers found that more “high-end” research is needed, not just retrospective studies.

The committee also assailed what it called a long-term underinvestment in care, as well as a lack of accountability of how resources have been allocated. Its final conclusion was that Congress will need to grant all relevant agencies the authority needed to make substantial changes as needed.

The study — which was undertaken by the Committee on the Quality of Care in Nursing Homes — was sponsored by The John A. Hartford Foundation, The Commonwealth Fund, Sephardic Foundation on Aging, Jewish Healthcare Foundation, and The Fan Fox & Leslie R. Samuels Foundation.

The National Academies of Sciences, Engineering, and Medicine are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine. They operate under an 1863 congressional charter to the National Academy of Sciences.

This is a developing story. Please check back for additional updates.