Nursing Home Reform in the Context of National Long-Term Care Services and Policy: The Devil in the Details of the National Academies Report

As the late Robert Kane pointed out, the term “nursing home” is inaccurate: most provide very little nursing, and few offer a homelike environment. No one wants to reside there until they need to, and even then, most residents wish to return to the community. The media love to malign them, they have been largely left out of Medicare and other federal financing initiatives, and their staff are paid less and given more responsibility than hospital workers. The attitude of the general public and most of the healthcare policy world is to avoid the topic. Most people do not want to contemplate becoming frail and being unable to maintain their own households; ageism may also play a role. Policymakers may not prioritize reform to the same extent as experts and advocates, given that nursing home care accounts for only 5% of national health expenditures (Centers for Medicare and Medicaid Services, 2020). Thus, it has been easy for the general public and the broader health policy community to ignore this corner of the health care delivery system. This complacency was shattered by COVID-19, which appeared to single out long-term care facilities with deadly precision. The first US setting to garner national attention because of a deadly outbreak was a nursing home (Baker and Weise, 2020; McMichael et al., 2020). During the months that followed, nearly 40% of US deaths from the virus were in nursing homes and other long-term care settings (Girvan and Roy, 2020). As the pandemic progressed and the virus spread throughout the country, that proportion gradually decreased and nursing homes achieved high vaccination rates; still, by mid-2022, the cumulative morbidity and mortality from COVID-19 in US nursing homes stood at 1,136,796 confirmed cases and 154,250 deaths among residents and 1,218,268 confirmed cases and 2500 deaths among staff (Centers for Medicare and Medicaid Services, 2022). This high rate of death in nursing homes has raised public awareness of the vulnerability of residents living in congregate settings as well as the people who care for them. Residents of such settings typically suffer from multiple chronic conditions and many from cognitive impairment, which makes isolation more difficult. Although COVID-19 may have been a catalyst for examining nursing home quality, many of the underlying factors that put nursing homes at risk, such as staffing shortages, inadequate training, and a complex financing and regulatory environment, have been at play for many years. Spurred by the severe impact of COVID-19 in nursing homes, the National Academies of Sciences, Engineering, and Medicine (NASEM) convened a committee to create a report on the quality of care in nursing homes. The committee was supported by funding from the John A. Hartford Foundation, the Commonwealth Fund, the Sephardic Foundation on Aging, the Jewish Healthcare Foundation, and the Fan Fox & Leslie R. Samuels Foundation. The committee was made up of 14 academics, two consultants, and one government official. The NASEM committee's work is also represented in several articles and an accompanying editorial in this issue. The committee was charged with examining how the U.S. delivers, finances, regulates and measures the quality of care in nursing homes. The target audience included the US Congress, the US Centers for Medicare & Medicaid Services (CMS), the US states, the nursing home industry, consumers, and other interested and involved parties. The NASEM committee hoped that similar to the 1986 study, its work would lead to significant improvement in the quality of care in nursing homes (U.S. Congress, 1987). The NASEM committee and staff worked intensively for over a year to develop a comprehensive, evidence-supported report. They conducted a thorough literature review; discussed the relevant issues and evidence at multiple meetings; heard and deliberated on presentations from three dozen leaders from industry, government, and consumer groups; and received and responded to 16 additional experts' comments on their preliminary report. Although the committee may be criticized as overrepresenting academics, the resulting 604-page document is by far the most comprehensive review and set of recommendations articulated in many years (National Academies of Sciences, Engineering, and Medicine, 2022). The authors of this editorial want to applaud the work of the NASEM committee for this important and timely project. The report correctly insists that nursing home quality issues are systemic and that comprehensive reform is needed to effect meaningful change. It therefore emphasizes that all elements of the report's recommendations—including care goals, policies, processes, systems, workforce, financing, quality measurement, and performance improvement—should be considered as a package, not in a piecemeal way; comprehensive reform is needed to effect meaningful change. The articles in this issue highlight several of the key themes that emerged from the NASEM report. There are a number of major recommendations that we believe should be highlighted because of their boldness, novelty, or overall importance. They include incorporating resident and family experience into measures of nursing home quality (recommendation 6A); making design changes that prioritize private bedrooms and bathrooms and smaller units (recommendation 1E); ensuring that Medicaid payments are adequate to cover the delivery of high-quality care (recommendation 4B); addressing ownership transparency and accountability (recommendations 3A, 3B, and 5D); and promoting a federal initiative to spur adoption and upgrade of health information technology (recommendations 7A, 7B, and 7C). The report does, however, have some limitations, many of which stem from specific areas not being addressed because they were not a part of the committee's statement of task or there was no evidence of impact. For example, the committee was not charged to articulate a vision of the present and future role of nursing homes in the evolving US long-term care system. Following the release of the 1986 report, the long-term services and supports (LTSS) landscape dramatically changed. Two key changes are that there has been marked growth in assisted living and home- and community-based services (HCBS) and that Medicaid, which is the largest funding source for nursing homes, now spends more on HCBS (Murray et al., 2021). These changes, as well as the fact that long-term acute care hospitals (LTACHs) vie for similar populations, demonstrate considerable overlap and a need for more deliberate planning of the interrelationships between these entities. It is quite possible, for example, that the continued expansion of federal and state support for LTSS in HCBS (including assisted living) will continue to exert downward pressure on the nursing home population. Thus, the nursing homes of the future may largely consist of an increasing proportion of residents receiving postacute care (Sloane, 2022), whereas persons with advanced dementia and acute functional impairment will reside in assisted living (Zimmerman et al., 2022). Also, nursing homes have been serving an increasing number of people with severe mental illness (Fashaw et al., 2020), raising important questions about the nature of the workforce needed to support a population with behavioral expressions. If these trends continue, nursing homes may look different than what is envisioned by the NASEM report based more on prior population profiles. Care resources might then need to be modified to more heavily emphasize physical care, communication disciplines, one-on-one (as opposed to group) services, behavioral health, and palliative care. In a similar vein, the committee's recommendations do not address whether and how postacute care should be paired and integrated with other long-term care services. As Kane (2010) noted nearly two decades ago, the goals of postacute care differ from those of long-term care, making it difficult, if not impossible, to have a facility that excels at both sending patients home and creating a home. Although there is some evidence of correlation in quality of care for postacute and long-term care residents, this appears to be limited to vaccination—a domain that is relevant for both populations (Wang and Hefele, 2021). Therefore, an important question to ask is whether postacute care should be provided in separate settings from long-term care and, if not, how to better accommodate these two disparate service models within a single entity (Sloane, 2022). In support of the NASEM report, these issues could be seen as future concerns, whereas the present is so in need of change that thinking about the shape of the future would merely muddy policy decisions. The recommendations for demonstration projects on alternative payment models (recommendations 4A, 4D, and 4E) could go further by, for example, considering incentives for delivering postacute care in single-purpose facilities. This could stimulate investment in regions of the country that have a limited supply of inpatient rehabilitation. A more pragmatic issue regarding which the report falls short is how to really professionalize the role of the certified nursing assistant (CNA). The recommendations provided are soft: “competitive” wages and benefits, 45 additional hours of training, and “consideration” of issues such as wage floors and student loan forgiveness. One stronger recommendation does, however, call for state and federal governments and/or nursing homes to cover the cost of CNA training and continuing education, although no specific suggestions for implementing this recommendation are made. In contrast, the report more firmly recommends using registered nurses as supervisors instead of licensed practical nurses and advises that social workers should have, at minimum, a bachelor's degree in social work and 1 year of experience. The report should be lauded for placing the goal of supporting person-centered care at the very top of its list of recommendations (recommendation 1A). As noted above, recommendation 6A and the closely related 6B and 6C are important improvements to the current quality measurement regime. Placing resident satisfaction on par with physical health is an important step toward a system that recognizes that nursing homes are responsible for the full spectrum of Maslow's hierarchy of needs (Kusmaul et al., 2022; Maslow, 1943). The report could have gone further, however, by recommending tight integration of the concepts of care planning and public reporting as they relate to quality of life. Valid and reliable methods for measuring residents' quality of life (Kane et al., 2003; Van Haitsma et al., 2014) and incorporating their preferences into care planning (Degenholtz et al., 2014) and quality improvement (Abbott et al., 2022) have existed for some time. The CMS has recently issued guidance for states to measure and publicly report statistics on participant choice and control for people receiving Medicaid-financed HCBS (Tsai, 2022). This is ironic considering that HCBS has long lagged behind the nursing home sector in terms of standardized assessment. Analogous to the various physical and behavioral health outcomes that are publicly reported, the Minimum Data Set should be revised not only to capture resident preferences but also to directly measure quality of life, and a composite indicator should be publicly reported. Relying on a separate measure of participant experience (i.e. the Consumer Assessment of Health Provider Survey—Nursing Home) that is not integrated into care planning has a low likelihood of affecting the delivery of care. The report primarily focuses on the role of CMS; however, it does not address the role that states have played with regard to long-term care financing (e.g. the WA Cares Fund) or in improving quality of care and quality of life. Minnesota and Ohio are leaders in collecting and publicly reporting both residents' and family members' ratings of quality of life and satisfaction, and Ohio has experimented with incorporating measures of person-centered care into value-based purchasing. Although the majority of Medicaid long-term care spending has shifted to HCBS, there is wide variation across states in the number of people using Medicaid-financed HCBS compared with nursing homes (rebalancing). Efforts to increase the use of HCBS have had an impact on the case mix of people living in nursing homes by providing alternatives for people with relatively low care needs, which clearly has increased demands on staff. Finally, nearly half of US states have implemented some form of managed long-term services and supports (MLTSS). These programs pay privately managed care plans a fixed monthly premium to finance all long-term care needs for the Medicaid population. These plans are incentivized to shift care to HCBS and also have the flexibility to issue reimbursement and implement value-based payment schemes. Although CMS has outlined standards and quality measures for MLTSS plans, the states play a major role in implementing these programs and ensuring that standards are being met. Indeed, in many states, the role of Medicaid has shifted from that of a direct payer to overseeing a marketplace of competing private insurance plans. Although states have new tools at their disposal, the overall effectiveness of MLTSS is not yet well understood. To the extent that the NASEM report assigns responsibility for implementation to states, the new role that states are playing will need to be considered. The NASEM report highlights the important role that health information technology can play in improving quality of care in nursing homes. The final set of recommendations (7A–D) focus on adoption, interoperability, and continued research. However, there are other forms of technology that can improve quality of life and quality of care that should be encouraged and studied. For example, the restrictions on visitors during the COVID-19 pandemic led to innovative uses of video calling (Davitt and Brown, 2022). Another important area where technology is finding a use in nursing homes is with robotic companions (Moyle et al., 2019; Pu et al., 2019). The research and policy world needs to consider how these and other innovations such as discreet monitoring will play a role in the coming years, especially the potential for technology to extend the ability of a limited workforce to care for a growing older population. Finally, the report arrived during a complicated political moment in the United States; the two political parties are polarized along lines that make complex changes to the regulation and financing of nursing homes or any significant new funding seem unlikely. The conditions for creating consensus around a new federal entitlement to long-term care, for example, seem out of reach. It is clear to the authors of the NASEM report, however, that disability, frailty, and old age affect everyone. All families face decisions about how to care for their relatives. The COVID-19 pandemic revealed that the problems facing nursing homes are universal. Hopefully, this crisis and tragic loss of life will be catalysts for change. The NASEM report is an important roadmap for needed reform to US nursing homes. It stands with the landmark report from 1986 and, if implemented, will undoubtedly lead to substantial improvements in the quality of life and quality of care of older adults and people with disabilities who live in those settings. However, there are important limitations that policymakers, researchers, and providers should bear in mind. The need for reform and the scope of the challenge are broader than the mission of the NASEM report. This supplement is sponsored by The John A. Hartford Foundation. All authors are active members of the Research in Quality of Care Interest Group of The Gerontological Society of America. None. J. Travers served as the contact editor for the supplement, in which this article is included, but was not involved in the review or decision for the article.