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 healthcare 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 healthcare continuum. 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 is more acute than ever and will necessitate immediate response and a long-term strategy addressing payment, the workforce, and leadership.

One of the first issues to be addressed is adequate funding to implement evidence-based quality care for this complex population. Payment rates to nursing homes should be adjusted yearly, as are Medicare rates, and correspond to the cost delivery of evidence-based quality care as determined by appropriate measurements reflective of person-centered care, which incorporates the wishes of the resident and of care that delivers age-sensitive outcomes. Another adjustment is implementing a pay-for-performance approach that is becoming common in other parts of the healthcare system. There is some limited reimbursement provided for certain factors that CMS deems related to quality, but the metrics look at specific criteria such as pressure ulcer incidence or number of falls, but they do not measure the resident's quality of life or the degree of care planning around "what matters" to the resident. Finally, there needs to be reform in the structure of the Medicare and Medicaid program, which might require an additional Medicare tax such as a Part E as well as more comprehensive coordination of Medicare and Medicaid benefits. 

The second issue is workforce capacity and preparedness to deliver person-centered, quality, and cost-effective care. This requires adequate staffing, appropriate education of that staff, and leadership. None of this, however, has ever been considered in setting policy. CMS requires only one RN for 8 hours/day in a nursing home. The other 16 hours can be covered by a licensed practical nurse with less than one year of technical education. There is a broad consensus that at least 4.1 hours of care per resident by direct caregivers and nurses is necessary to avoid systematic poor care.

Educational preparation of the workforce for long-term care has never been emphasized for nurses or nursing assistants. Education of nurses and direct caregivers must sufficiently prepare them to understand the multi-dimensional processes of aging and to provide age-sensitive support and care across the healthcare continuum. And, historically, compensation and benefits in nursing homes have been inferior when compared to hospitals. Unless competitive and livable wages are provided to the long-term care workforce, recruitment and retention will continue to be a challenge.  

And, third, there needs to be a federal standard of education for nursing home administrators. While most states require a minimum of a bachelor's degree to qualify for a nursing home administrator license, some require only an associate degree. Some also require master's degrees in public health, nursing, long-term care administration, health services administration, or business administration. The lack of a standard preparation of leaders in long-term care contributes to the continuation of top-down management reminiscent of the last century model of leadership. We need to develop leaders and standardize qualifications for leadership positions in long-term care that can drive a person-centered culture for residents and staff which supports decentralized decision making, collaboration and teamwork, continuous quality improvement, and a focus on quality-of-life and "what matters" for each unique resident. 

With the impetus of increased public awareness about the challenges of providing long-term care in this country, additional money and resources are being directed to home and community-based services. While resources to allow people to age in place are necessary, the need for residential long-term care will not disappear. We need to ensure that our long-term care facilities have an adequate workforce with strong leadership and appropriate financial support to provide the appropriate care to people who need to have that level of skilled nursing.

Encourage your state and federal elected officials to focus on the spectrum of long-term care. These and other barriers to quality care in nursing homes, assisted living, and home and community-based care need to be addressed through legislation and policy. 

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