How Empowering Nursing Home Staff to Take Risks Can Improve Care: ‘We Need to Pay for What We Value’

Through their work with consulting firm Copernicus Inc., CEO Claudia Blumenstock and consultant Ellen Bartoldus have heard countless firsthand stories of the strains that COVID-19 has put on nursing home staff across the country.

And as former nursing home administrators themselves, the pair has a clear vision for how to fix the endemic problems that helped contribute to an unprecedented wave of illness and death in long-term care — a vision that focuses on empowering frontline leaders to make major decisions, and rewarding their work with adequate pay and support.

“As a country, we need to pay for what we value,” Bartoldus told SNN during a recent phone conversation. “We say we value elders, we say we value value good staff — but we’re defining this good staff as unskilled labor.”

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That value includes an emphasis on boosting wages, which have taken center stage in the national discussion around elder care.

Studies have suggested that staffers working at multiple facilities helped to introduce the novel coronavirus into nursing homes that were otherwise shut down to the outside world. With higher wages for certified nursing assistants (CNAs) and other frontline caregivers, employees might not have needed to take shifts across multiple facilities.

“It’s mostly brown and black women that are providing that care,” Bartoldus said. “We don’t pay them a living wage. They have to work two jobs in order to survive, and then we expect an incredible quality of care from them — and we’re not willing to really pay for what we say we value.”

Already a persistent issue in the long-term care landscape, properly compensating caregivers for their work has taken on even greater urgency as certified nursing assistants (CNAs), registered nurses (RNs), and other nursing home staffers have found themselves — through no doing of their own — as the first line of defense in the nation’s most common and intense COVID-19 hotspots.

And while, for the vast majority of health care providers, the COVID-19 patients passing through doctors’ offices and hospitals are relative strangers, the relationship between nursing home staff and their patients is fundamentally closer — making the emotional toll that much more devastating, Bartoldus said.

“In the nursing home, the staff knew these elders for any number of years. They had relationships with them; they knew who they were, they knew who their families were,” she said. “Right now, we actually have a pandemic of grief operating in our nursing homes — and unless we begin to acknowledge that, face it, and give ways for the staff to be able to work through it, we’re going to have burnout, and a tremendous amount of people leaving the field going forward.”

In their conversations with leaders and frontline staffers across the country, they’ve heard stories of workers who restarted kicked habits like smoking amid the stress and the looming specter of “pre-guilt,” or the constant fear of being the person who unwittingly brings the novel coronavirus into a facility.

“[It’s] this thing that consumes them and doesn’t let them sleep at night, because they’re so afraid that it will be them that brings it either in for the first time, or brings it back to their facilities,” Blumenstock said. “They carry this stress and this worry all the time.”

But improving staff pay and morale is only one part of the necessary reform steps. True change in long-term care, according to Blumenstock, will require tough conversations — both with family members and residents, and within the industry itself.

“We know that there are a group of advocates that would like to see nursing homes not exist anymore — and I think that it’s important to ask the hard questions,” she said. “We can understand that putting relatives into nursing homes isn’t our first choice, and maybe there have to be other decisions, and maybe we have to close nursing homes. But if that’s the case, what’s the plan?”

To start, Blumenstock and Bartoldus called for frank discussions with families about what their loved ones want out of long-term care, as well as the realistic types of outcomes that can be expected.

In the past, they’ve had success with educating family members who in turn were able to provide advocacy and support for nursing homes in their community, but widespread adoption of that strategy will rely on breaking down the barriers of suspicion that often exist on both sides of the operator-family equation — as well as a willingness, generally uncommon in the United States, to directly confront the concept of death as a part of aging.

“How do we start to have the conversation, so that we’re facing the thing that perhaps scares the most?” Blumenstock said. “In order to provide the kind of care that we all want to see happen in nursing homes, we have to have these difficult conversations that no one’s comfortable with.”

The conversations surrounding the future of post-acute and long-term care have already begun to include intense calls for additional regulation and stricter fines, the latter of which the Centers for Medicare & Medicaid Services (CMS) has implemented for facilities with a pattern of infection-control problems.

In the former administrators’ view, any plan for regulatory reform should have one key tenet at its center: How does this decision affect the residents’ quality of life, and the nursing home staff’s ability to provide the best quality of life possible?

For instance, reimbursement shifts are one way that CMS can attempt to secure better outcomes for residents: The Patient-Driven Payment Model (PDPM) for Medicare reimbursements, implemented last October 1, was explicitly designed to reduce the provision of unnecessary therapy services for profit, while also more closely aligning payments with individual resident needs.

But the need for nursing home staff to become fluent in a new set of coding and billing issues can take attention away from resident care.

“We see time being taken away from residents in order to satisfy the the reimbursement requirements, and optimizing the dollars, but is that optimizing the quality of life for residents?” Blumenstock said. “I think we have to start asking some those questions: What does the quality of life look like for a resident? Asking residents: What does the quality of life look like for you? And trying to build on that — not to a punitive place, but to a very practical place.”

Finally, the pair called for a deeper focus on fostering decision-making skills among frontline caregivers and building-level leaders. The facilities that took action against COVID-19 the earliest, those that did not wait for authorities to implement stricter infection-control and visitation measures, had a significant leg up on preparations.

One building in particular, the Maryland Baptist Home for the Aging in Baltimore, has earned heaps of media praise for its director’s decision to lock the facility down on February 26, as soon as he heard the president attempting to downplay the risk.

“We didn’t wait for guidance from the Centers for Disease Control or from the Maryland Department of Health or from Baltimore City,” Rev. Derrick DeWitt told the Baltimore Sun. “We did what we thought was prudent at the very beginning of the pandemic.”

That’s not necessarily a call that nursing home leaders are encouraged or even trained to make; during Bartoldus’s administrator training, the concept of strategic decision-making was never even discussed, she said. In addition, the heavily regulated nature of nursing homes in general can make their leadership wary of any unilateral decision that doesn’t follow written state and federal guidance to the letter.

But in their work as consultants, Bartoldus and Blumenstock have seen firsthand the benefits of empowering leaders to make bold choices based on rapidly evolving situations.

“We’ve found that the providers that have been the most successful are the ones that have taken the risks, that have made decisions that are in the best interest of their residents as opposed to what the popular thing is to say in the moment — because I don’t think anybody has good, hard facts right now that really are guiding us in a way that that creates safety,” Blumenstock said.

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