The COVID-19 pandemic has highlighted the limitations of the current system of nursing home care in the united states, and without major changes, nursing homes are not – and will not – be able to deal with major pandemics such as the current one, according to several authors writing in the National Academy of Medicine publication NAM Perspectives.
The commentary piece published Monday by John A. Hartford Foundation president Terry Fulmer, Milbank Memorial Fund president Christopher Koller, and Columbia University professor John Rowe — pointed out several factors leading to the current toll of COVID-19 in skilled nursing factors. These include the history of nursing homes in the U.S. and the current payment structures for the care provided in these facilities.
“Nursing homes were never, and will never, be equipped to deal with infectious disease outbreaks unless major changes are made, including redesign and payment reform,” Fulmer said in a statement announcing the commentary. “These facilities and their dedicated workforce have borne the brunt of COVID-19 and need actionable solutions to prevent dire outcomes from continuing to happen.”
When Medicare and Medicaid were passed as amendments to the Social Security Act in 1965, the former was focused on acute care, while the latter only covered long-term care in institutions.
“This 1965 amendment created a cultural and economic preference for institutional long-term care,” the authors wrote. “The majority of nursing homes constructed as a result were with a distinctly institutional design — with double occupancy rooms — which has been an especially challenging factor during the COVID-19 pandemic.”
To this point, the authors argued that one of the crucial steps forward is revising the physical design and existing operating model of nursing homes, positing that many long-stay patients with multiple comorbidities could be better served in smaller facilities — such as the Green House model, which saw much lower COVID-19 infection rates relative to the overall nursing home population at least through the end of May.
They also noted the financial challenges inherent in the model, especially for for-profit facilities that tend to be large for the sake of efficiencies, though some operators have found ways to make the model viable.
For that reason, the commentary authors argued that residents need to be better matched with the most appropriate care settings, which might include providing more supports for home-based care, and “a substantially strengthened PACE (Program for the All-Inclusive Care of the Elderly) program.” They also advocated for increasing pay and training for workers.
Most of those workers are below age 55 and have a high school education or less — and make $30,000 or less a year.
“This low-paid, poorly trained workforce must address a great heterogeneity of need among nursing home residents,” the authors wrote.
Altering the future of short-stay rehabilitation patients coming out of the hospital might include the return of extended care wings contiguous with acute facilities, which have some advantages in their proximity to the primary care and specialty providers during the post-acute phase of a treatment episode, they said.
“However, the design, staffing, delivery, and financing of post-acute care is very different from acute care, and hospitals may not be able to effectively manage this population,” they wrote. “Many hospitals may not be able to afford the investment required to establish such extended care units. Most U.S. hospitals are nonprofits with slim operating margins close to 1–2% and limited sources of capital to invest in new facilities and programs.”
And when it comes to sources of income, the Medicaid and Medicare programs that drive nursing home revenue are going to be critical to any new model that emerges. Most long-term nursing home residents have gone through their personal assets and depend on Medicaid for payment; meanwhile, 43% of nursing home residents stay less than 100 days when receiving skilled nursing care.
“As the primary financiers for short- and long-term nursing home stays respectively, the payment rules of Medicare and Medicaid will play crucial roles in realizing a new vision for the appropriate services and settings for the care nursing homes currently provide,” they wrote. “Despite these hurdles, the authors of this paper argue that the inadequacy of the current system has been put on display, and it is time to develop new strategies to better match the care provided with the needs of the varied subsets of the institutional long-term care population.”