Home care nursing and funding system needs overhaul, report says |


NEW YORK – Nursing home residents are subjected to inefficient care and poor staff, while facility finances are shrouded in secrecy and regulatory loopholes go unenforced, according to a report Wednesday that called for sweeping changes in an industry whose failures have been brought to light by the pandemic.

For anyone who has seen the scourge of COVID-19 on the nation’s most vulnerable, the findings of the National Academies of Sciences, Engineering, and Medicine may seem disappointing but unsurprising, as shortcomings in the long-term care system were evidenced by more than 150,000 deaths of inhabitants. The authors of the 605-page report insist it could be a push to address issues that have been little more than lip service for decades.

“The public is so concerned about the quality of care that most people are really worried that their families will have to be in a nursing home,” said Betty Ferrell, a nurse who chaired the report’s committee. “We are very optimistic that our government officials will respond to what has truly been a travesty.”

The report covers a wide range of long-term care, from granular details such as how facilities are designed to fundamental issues that would require massive political capital and investment to address. Among them: the authors argue for the creation of a new national long-term care system that would exist outside of Medicaid, the program that is at the center of most long-term care funding.

The likelihood of such a proposal successfully reaching Congress seems remote in the current political climate. The most recent federal attempt to reform long-term care funding was a voluntary long-term care insurance program known as the CLASS Act. It was included in the Affordable Care Act, but was later repealed when the Obama administration found it unworkable.

“It’s been a long time since we as a country wanted to dig in and reform the way we fund, pay for, regulate and deliver nursing home services,” said David Grabowski, a nursing home expert. and a professor at Harvard Medical School who served on the report’s commission.

The biggest industry lobby groups have insisted that the reforms must be met with increased government funding.

The American Health Care Association said “what we can’t support are unfunded warrants.”

Katie Smith Sloan, who runs LeadingAge, which represents nonprofit nursing homes, called the report a “sharp wake-up call” to an industry “in desperate need of an overhaul”, but also said that the success of the system overhaul would depend on how funding issues are resolved.

“As policy makers consider how to implement the report’s recommendations, they must support their actions with sufficient funding to make change a reality,” she said. “Without that, the work of the committee will be useless.”

On the issue of nursing home staffing, which advocates have repeatedly said is too weak, too poorly trained and too underpaid, the report’s authors called for facilities to have at least one registered nurse on duty at all times and that an infection prevention and control specialist and social worker to also be on staff.

More generally, across all staff in homes, including care aides who make up the bulk of frontline caregivers, the authors called for further study into optimal staffing.

Industry lobbyists fought hard against tougher staffing requirements. Federal law only requires that nursing homes have enough staff to meet residents’ needs, but almost all interpretation of what that means is left to the states. President Joe Biden has also called for establishing national staffing minimums.

Among the most common topics in the report, but which nevertheless impact the daily lives of residents, the authors call on homes to favor private rooms and bathrooms rather than communal ones which can fuel infections and underline the institutional framework. And in a stark reminder of the bleakness of care home life, the report notes that most residents spend “little or no time outdoors”, calling for facilities to make outdoor access more accessible. .

The proposals, Grabowski said, have the potential to improve the days of residents who, even when having their basic medical needs met, are often lacking in other areas of their lives.

“I think the average nursing home resident has an okay quality of care but a poor quality of life,” Grabowski said.

Advocates for nursing home residents have long advocated for drawing attention to homes’ shortcomings, and the pandemic has given them a media spotlight. But decades of political inaction and industry resistance are hard to overcome, and what the report might trigger remains unclear.

A precursor to the study, “Improving the Quality of Care in Nursing Homes” from 1986, was also a product of the National Academies. Some of the issues in this report were reflected in the far-reaching Nursing Homes Reform Act of 1987, which created the regulatory framework that homes still operate today. Others remain unanswered 36 years later.


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