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Commentary|Articles in Press

The Nursing Home Crisis: Prognosis Guarded

Published:May 27, 2022DOI:https://doi.org/10.1016/j.amjmed.2022.05.003
The Nursing Home Crisis: Prognosis Guarded
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      On February 28, 2022, the White House released a detailed “Fact Sheet” replete with plans to “improve the safety and quality of nursing home care, hold nursing homes accountable for the care they provide, and make the quality of care and facility ownership more transparent.”

      The White House, Briefing Room. FACT SHEET: Protecting seniors by improving safety and quality of care in the nation's nursing homes. February 28, 2022. Available at: https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/. Accessed March 22, 2022.

      The proposed reforms were further highlighted during the State of the Union Address, wherein President Biden noted that “Medicare is going to set higher standards for nursing homes and make sure your loved ones get the care they deserve and expect.”

      The White House. STATE OF THE UNION ADDRESS. March 1, 2022. Available at: https://www.whitehouse.gov/state-of-the-union-2022/. Accessed March 22-2022.

      The hoped-for reforms are intent on ensuring that “every nursing home provides a sufficient number of staff who are adequately trained to provide high-quality care.”

      The White House, Briefing Room. FACT SHEET: Protecting seniors by improving safety and quality of care in the nation's nursing homes. February 28, 2022. Available at: https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/. Accessed March 22, 2022.

      The new paradigm will also seek to ensure that “poorly performing nursing homes are held accountable for improper and unsafe care and immediately improve their services or are cut off from taxpayer dollars.”

      The White House, Briefing Room. FACT SHEET: Protecting seniors by improving safety and quality of care in the nation's nursing homes. February 28, 2022. Available at: https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/. Accessed March 22, 2022.

      Concurrent efforts will be undertaken to ensure that “the public has better information about nursing home conditions so that they can find the best available options.”

      The White House, Briefing Room. FACT SHEET: Protecting seniors by improving safety and quality of care in the nation's nursing homes. February 28, 2022. Available at: https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/. Accessed March 22, 2022.

      In this Commentary, we review the newly released nursing home reform proposal and discuss the likelihood of the consummation thereof.
      At the time of this writing, in excess of 1.5 million seniors reside in >15,500 Medicare- and Medicaid-certified nursing homes across the nation.

      The White House, Briefing Room. FACT SHEET: Protecting seniors by improving safety and quality of care in the nation's nursing homes. February 28, 2022. Available at: https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/. Accessed March 22, 2022.

      Most of these facilities are accredited to function as short-term skilled nursing facilities and as long-term nursing homes for the aged.

      U.S. Department of Health and Human Services, Office of the Inspector General. Nursing homes. January 18, 2022. Available at: https://oig.hhs.gov/reports-and-publications/featured-topics/nursing-homes/. Accessed March 22, 2022.

      Over 69% are deemed to be for profit, that is, owned by corporations or private equity.

      Kaiser Family Foundation. Harrington C, Carrillo H, Garfield R, Squires E. Medicaid: Nursing facilities, staffing, residents and facility deficiencies, 2009 through 2016. April 3, 2018. Available at: https://www.kff.org/medicaid/report/nursing-facilities-staffing-residents-and-facility-deficiencies-2009-through-2016/. Accessed March 22, 2022.

      It took the coronavirus disease 2019 (COVID-19) pandemic to bring the nursing home crisis into sharper focus. In what many view as a glaring distress signal, over a quarter of the national COVID-19 death toll (201,000 men and women) was ascribable to nursing home residents and staff.

      Kaiser Family Foundation; Chidambaram P. Coronavirus (COVID-19): Over 200,000 residents and staff in long-term care facilities have died from COVID-19. February 3, 2022. Available at: https://www.kff.org/policy-watch/over-200000-residents-and-staff-in-long-term-care-facilities-have-died-from-covid-19/. Accessed March 22, 2022.

      It is in wake of this grievous outcome that the Administration announced a series of reforms intent on “Improving Safety and Quality of Care in the Nation's Nursing Homes.”

      The White House, Briefing Room. FACT SHEET: Protecting seniors by improving safety and quality of care in the nation's nursing homes. February 28, 2022. Available at: https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/. Accessed March 22, 2022.

      Leading the nursing home reform toward “safe, adequate, and dignified care” are several new initiatives.

      The White House, Briefing Room. FACT SHEET: Protecting seniors by improving safety and quality of care in the nation's nursing homes. February 28, 2022. Available at: https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/. Accessed March 22, 2022.

      Paving the way is the conception of “minimum nursing home staffing requirement,” which requires the Centers for Medicare & Medicaid Services (CMS) to “propose minimum standards for staffing adequacy that nursing homes must meet.” Yet another initiative seeks to “reduce resident room crowding,” with an eye toward advancing privacy and dignity as well as reducing the “risk of contracting infectious diseases, including COVID-19.” A related initiative aims to “strengthen the skilled nursing facility value-based purchasing program” by linking payment for quality care to “staffing adequacy, the resident experience, as well as how well facilities retain staff.” Additional efforts will seek to “reinforce safeguards against unnecessary medications and treatments” such as antipsychotic drugs.
      With enhanced “accountability and oversight” in mind, the Administration intends to call on Congress to add $500 million to the CMS budget “to support health and safety inspections at nursing homes.”

      The White House, Briefing Room. FACT SHEET: Protecting seniors by improving safety and quality of care in the nation's nursing homes. February 28, 2022. Available at: https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/. Accessed March 22, 2022.

      Concurrently, the Administration will seek to “beef up scrutiny on more of the poorest performers.” In addition, plans will be drawn to “expand financial penalties” against “poor-performing facilities.” President Biden will also be calling on Congress to “raise the dollar limit on per-instance financial penalties levied on poor-performing facilities, from $21,000 to $1,000,000.” To complement the aforementioned initiatives, the Administration will seek to “increase accountability for chain owners of substandard facilities” while providing “technical assistance to nursing homes to help them improve.”
      With “increasing transparency” as a goal, the Administration aims to “improve the public transparency of facility ownership and safeguard nursing home residents.”

      The White House, Briefing Room. FACT SHEET: Protecting seniors by improving safety and quality of care in the nation's nursing homes. February 28, 2022. Available at: https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/. Accessed March 22, 2022.

      To this end, the Administration proposes to “create a database of nursing home owners and operators” and to “improve transparency of facility ownership and finances.” In parallel, the Administration is committing to enhancing its “Nursing Home Care Compare” rating website, which is “designed to help families pick a facility for their loved ones.” It is also the intent of the Administration to “examine the role of private equity” in the nursing home sector with an eye toward informing the public “when corporate entities are not serving their residents’ best interests.”
      To maximize the success of the aforementioned reforms, the Administration proposes the creation of “Pathways to Good-paying Jobs with the Free and Fair Choice to Join a Union.”

      The White House, Briefing Room. FACT SHEET: Protecting seniors by improving safety and quality of care in the nation's nursing homes. February 28, 2022. Available at: https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/. Accessed March 22, 2022.

      For example, the Administration will strive to ensure that “nurse aide training is affordable.” CMS, for its part will “launch national nursing career pathways campaign.” Finally, with an eye toward minimizing further COVID-19-related morbidity and mortality, the Administration proposes continued “COVID-19 testing” and “COVID-19 vaccinations and boosters” in long-term care facilities. Future efforts will seek to “strengthen requirements for on-site infection preventionists” as well as “enhance requirements for pandemic and emergency preparedness.” In so doing, the Administration hopes to “integrate pandemic lessons into nursing home requirements.”
      Yet another in-depth assessment of the nursing home sector was recently offered by a Consensus Study Report of the National Academies of Sciences, Engineering, and Medicine (NASEM) titled “The National Imperative to Improve Nursing Home Quality.”
      National Academies of Sciences, Engineering, and Medicine
      The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff.
      The National Academies Press, Washington, DC2022https://doi.org/10.17226/26526
      It was the aim of the NASEM report to ensure that “Nursing home residents receive care in a safe environment that honors their values and preferences, addresses goals of care, promotes equity, and assesses the benefits and risks of care and treatments.” Specifically, the NASEM report called for the development of a “well-prepared, empowered, and appropriately compensated workforce” that will be in a position to “deliver comprehensive, person-centered, equitable care.” In addition, the NASEM report called for increased “transparency and accountability of finances, operations, and ownership” and the creation of a “more rational and robust financing system.” Quality assurance that relies on “quality measurement and continuous quality improvement” and on “health information technology in all nursing homes” was similarly emphasized.
      Although opinions may vary as to the challenges that lie ahead, there is no doubting the extant nursing home crisis in the United Stares. As concluded by the NASEM report, “the way in which the United States finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, fragmented, and unsustainable.”
      National Academies of Sciences, Engineering, and Medicine
      The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff.
      The National Academies Press, Washington, DC2022https://doi.org/10.17226/26526
      Given the magnitude of the challenge, it is thus far from certain that the nursing home reforms proposed by the Biden-Harris Administration will reverse the status quo. After all, key elements of the nursing home reform enacted by way of the Omnibus Budget Reconciliation Act of 1987 (Public law No:100-203)

      CONGRESS.GOV. H.R.3545 - Omnibus Budget Reconciliation Act of 1987. Public Law No: 100-203. December 22, 1987. Available at: https://www.congress.gov/bill/100th-congress/house-bill/3545. Accessed June 9, 2022.

      4 decades ago have yet to be fully realized. Progress could also be set back by the slim Democratic majority in the Senate. Further setbacks could follow the upcoming midterm elections, which could well alter the legislative agenda of the House of Representatives, the Senate, or both. Comparable uncertainties apply to the outcome of the 2024 presidential election. Whether or not cooler bipartisan heads will prevail and coalesce to constructively address the nursing home crisis remains to be seen. Caring for the nations's elders should be an apolitical affair.

      References

      1. The White House, Briefing Room. FACT SHEET: Protecting seniors by improving safety and quality of care in the nation's nursing homes. February 28, 2022. Available at: https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/. Accessed March 22, 2022.

        View in Article

      2. The White House. STATE OF THE UNION ADDRESS. March 1, 2022. Available at: https://www.whitehouse.gov/state-of-the-union-2022/. Accessed March 22-2022.

        View in Article

      3. U.S. Department of Health and Human Services, Office of the Inspector General. Nursing homes. January 18, 2022. Available at: https://oig.hhs.gov/reports-and-publications/featured-topics/nursing-homes/. Accessed March 22, 2022.

        View in Article

      4. Kaiser Family Foundation. Harrington C, Carrillo H, Garfield R, Squires E. Medicaid: Nursing facilities, staffing, residents and facility deficiencies, 2009 through 2016. April 3, 2018. Available at: https://www.kff.org/medicaid/report/nursing-facilities-staffing-residents-and-facility-deficiencies-2009-through-2016/. Accessed March 22, 2022.

        View in Article

      5. Kaiser Family Foundation; Chidambaram P. Coronavirus (COVID-19): Over 200,000 residents and staff in long-term care facilities have died from COVID-19. February 3, 2022. Available at: https://www.kff.org/policy-watch/over-200000-residents-and-staff-in-long-term-care-facilities-have-died-from-covid-19/. Accessed March 22, 2022.

        View in Article
        • National Academies of Sciences, Engineering, and Medicine
        The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff.
        The National Academies Press, Washington, DC2022https://doi.org/10.17226/26526 (Accessed June 9, 2022)
        View in Article

      7. CONGRESS.GOV. H.R.3545 - Omnibus Budget Reconciliation Act of 1987. Public Law No: 100-203. December 22, 1987. Available at: https://www.congress.gov/bill/100th-congress/house-bill/3545. Accessed June 9, 2022.

        View in Article

      Article Info

      Publication History

      Published online: May 27, 2022

      Publication stage

      In Press Journal Pre-Proof

      Footnotes

      Funding: None.

      Conflicts of Interest: EYA and IGC declare no conflicts of interest.

      Authorship: Both authors have participated in the preparation of the manuscript.

      Identification

      DOI: https://doi.org/10.1016/j.amjmed.2022.05.003

      Copyright

      © 2022 Elsevier Inc. All rights reserved.

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