Necessary but Complicated: The Push for Nursing Home Reform

Following the tragic impact of the ongoing COVID pandemic on nursing home residents and staff, is there new momentum for reform?

Some signs point to yes.

In February 2022, the White House outlined actions through the U.S. Centers for Medicare and Medicaid Services (CMS). The measures would establish minimum staffing levels for nursing homes, encourage single-occupancy rooms, increase payment for meeting quality measures, and address inappropriate use of antipsychotic medications for people living with dementia.

Two months later, the National Academies of Sciences, Engineering, and Medicine (NASEM) released an extensive report with goals and recommendations for action. Perhaps its most striking conclusion is: “The way in which the United States finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, fragmented, and unsustainable.”

Long-term care experts welcome the renewed attention but are skeptical of the possibilities for sweeping change.

Tonya Roberts

“Some of the recommendations of the National Academies report are things that we’ve said have needed to occur for decades,” says University of Wisconsin–Madison School of Nursing Associate Professor Tonya Roberts, PhD, RN. She knows the issues well, having worked as an assistant director of nursing, nursing supervisor, and nursing assistant in nursing homes, before researching person-centered care in the setting.

“Some are even a reiteration of things that should have occurred back with the OBRA 87 regulations,” Roberts adds, referring to the Omnibus Budget Reconciliation Act of 1987, also known as the Federal Nursing Home Reform Act. “That suggests to me that without high-level policy changes, we’re just going to continue talking about the things we need to fix. Reimbursement is one of those critical levers to actually making some change.”

UW–Madison School of Nursing Emerita Professor Barbara Bowers, PhD, RN, FAAN agrees.

“Even CMS recognizes that it pays less than is required to provide minimal care,” Bowers points out. “There are a lot of nursing homes that are Medicaid only,” as opposed to private pay by residents or Medicare reimbursement for short-term rehab stays. “What does that say? They’re by design paying less than it costs to provide care.”

Barb Bowers

“Most nursing homes are just besieged,” says Roberts. “You’re trying to get staff and trying to keep staff. The Director of Nursing is passing out meds because there’s not enough staff. When you’re in that mode you can’t think about implementing a new anything.”

Despite the many challenges, Roberts and Bowers see reasons for hope.

“CMS has said they’re going to mandate staffing levels,” notes Bowers. “They have very clearly said they realize that will require more money. I don’t know where the money’s coming from, but at least there’s a recognition that nursing homes need more staff and more money to pay them.”

“The consumer interest in improving care has increased,” says Roberts. “COVID put a spotlight on nursing home problems. Previous changes were driven by grassroots consumer pressure. This is a good time for that to happen again. Mass pressure can be put behind implementing” the recommendations in the NASEM report.

Bowers’ and Roberts’ research suggests some smaller changes could have real impact.

“Right now, there’s an adversarial relationship between state surveyors and nursing homes,” says Bowers. “Several years ago, I visited Washington state to see their quality assessment nurses program. They had nurses who were connected to the surveyors but not part of the survey group. Their role was to go in and help nursing homes address problems, rather than fining them right away. That led to a flood of self-reported deficits by nursing homes. It showed the potential of allowing state oversight agencies to be helpful, not just punitive.”

“One of the recommendations is to expand our existing quality measures to include things beyond physiological markers of health,” says Roberts. “How does the way we provide care impact the meaning and the quality of people’s lives? It’s not just about whether people develop pressure ulcers.”

The NASEM report specifically mentions the Consumer Assessment of Healthcare Providers and Systems, or CAHPS, surveys.

“The recommendation to use CAHPS measures is a start,” says Roberts, “They include questions around quality of life. There are questions about choices, autonomy, and dignity. These are things that really matter to nursing home residents and their family members. And they have largely been absent from what we assess and evaluate.”

The NASEM report highlights the need for research in several areas, including care delivery models, staff training and advancement, and culturally tailored interventions to address disparities. While agencies have often been reluctant to support nursing home research, the NASEM report calls on the National Institutes of Health, Agency for Healthcare Research and Quality, and other sources to fund this work.

“Most of us in this field want to do this research,” says Roberts. “But we struggle to find the funding. We have to identify those gaps and consider the additional infrastructure needed to act on these recommendations.”

“I do think there is both more energy behind making changes and, possibly, a more receptive audience,” says Bowers.

–Diane Farsetta