Essential Reform in Long-Term Care

long term care


Our nation’s 15,000 nursing homes became “ground zero” in the early days of the COVID-19 pandemic accounting for nearly 5% of all cases and nearly 40% of deaths attributed to the pandemic.1 The virulence of COVID-19 coupled with the current state of nursing homes created the perfect storm that led to so many deaths. While the vast majority of nursing staff strived to provide the best possible care, we were witness to the impact of the shocking lack of resources and reporting that severely hampered the ability to pivot from everyday care to effective infection prevention and crisis management. The pandemic put a spotlight on the historical neglect of long-term care. Nursing homes have been marginalized, even siloed, and denied a seat at the health care table for policy and reimbursement issues.

Although residential long-term care is historically thought of as being simply custodial, the care needed in these settings is actually some of the most complex care delivered across the health care continuum. Most residents have multiple chronic diseases and very often have dementia as well. There are no protocols to prescribe care because each individual has different multiple conditions. With the increase in the number of people living to 85 and beyond, and the increase in complexity of those living in residential long-term care, the need for quality nursing homes—nursing homes that provide the right care at the right time by the right staff—is more acute than ever. To provide this kind of care requires leadership that understands how policy decisions made at the federal and state level have impacted the nursing homes over the years, envisions and advocates for policies that will serve our growing older population in the decades to come, and assumes responsibility for leading the industry in providing cost-effective and person-centered quality care.

Government regulation has been the method used to ensure quality care in nursing homes. The Nursing Home Reform Act was passed as part of the Omnibus Reconciliation Act of 1987 (OBRA′87).2 It requires nursing homes participating in Medicare and Medicaid to be aligned with specific quality “rules of care.” These “rules” focus on quality as well as the residents’ rights and person-centered care. Embedded in the Affordable Care Act (2010) are regulations to ensure transparency and accountability in long-term care and prevent resident abuse. However, the way for which the United States regulates and pays for nursing home care has made the actual implementation of any regulations nearly impossible and this was made highly visible during COVID-19. Furthermore, regulations are largely state-driven and vary greatly from state to state. There has never been a system to use evidence as a predictor of quality to determine compliance with the “rules of care.” Oversight is usually punitive resulting in fines, probation, or even closure and any remediation comes at what is often a substantial financial burden to any nursing home often requiring the engagement of outside consultants for which the nursing home absorbs the bill.

Many of the issues contributing to this perfect storm are long-standing and will necessitate both immediate response and a long-term strategy. It is time to stop blaming and look for lessons learned from the devasting loss in the wake of COVID-19. Initial responses during the pandemic included an emphasis on infection control infrastructure in long-term care and crisis management. Educational programs for all levels of nursing home staff on these issues are abundant. Nursing homes used travel nurses and agency nurses to increase needed professional staffing. Visits from outsiders were stopped and regular testing for staff and residents was made available. Many states stepped up their surveillance of infection control practices along with the fines for noncompliance. The Trump administration established a commission to make recommendations to improve the quality and safety of care in nursing homes. These were just some of the immediate responses to an overwhelming tragedy—the avoidable death of more than 40,000 residents in congregate living. However, quick fixes and reports that have no resources to enable the implementation of recommendations will only go so far. Unless we address the long-term strategies of payment reform for nursing homes which is necessary for the development of strong leadership and an appropriate workforce to navigate this industry into the future, we will leave a gap in care for those older adults who will need institutional care.


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