One Federal Report Was Never Going to Solve Systemic Nursing Home Problems. The Real Work Begins Now

A White House task force this week released an exhaustive report detailing the struggles and failures that the nation’s nursing workers and residents have endured over the last six months, but there wasn’t much information in its 186 pages that should have come as a surprise to anyone following the space.

A coherent, coordinated, and strong federal plan to distribute testing supplies and personal protective equipment remains vital to identifying COVID-19 cases and stopping further spread.

Family visitation is an essential human right that must be allowed whenever possible, with clear and evidence-based safety guidance for operators and their workers.

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Providers must improve communication flow, which so often broke down during the peak of the outbreaks, between facilities and families.

The long-term care workforce requires substantial expansion and support, from an increased role for higher-level specialists like infection preventionists and registered nurses, to substantially better wages and standardized training for the frontline certified nursing assistants (CNAs) who spend so much time in direct contact with frail elders — and who have thus put themselves at serious risk of infection during every shift.

The physical layout of most nursing homes has been insufficient to meet the demands of an increasingly medically complex resident population for a decade or more, and operators need to implement short-term fixes to weather COVID-19 — while also investing in brand-new buildings with infection control baked into every design feature.

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The nursing home sector, and the federal and state government agencies that regulate it, most likely didn’t need a 186-page report to tell them these things. Anyone who has worked in a facility, or at a company that operates them, or at a state health department that inspects them, should have been able to rattle off at least some of these suggestions off the top of their heads, if not most.

As I write, the Coronavirus Commission for Safety and Quality in Nursing Homes report hasn’t yet been public for 24 hours, and it’s already generated a wide swath of opinions and reactions.

At the top of the pyramid, Centers for Medicare & Medicaid Services (CMS) administrator Seema Verma took the report as validation of her agency’s work over the last six months.

“In tasking a contractor to convene this independent Commission comprised of a broad range of experts and stakeholders, President Trump sought to refine our approach still further as we continue to battle the virus in the months to come,” Verma said in a statement. “Its findings represent both an invaluable action plan for the future and a resounding vindication of our overall approach to date. We are grateful for the Commission’s important contribution.”

Commission member David Grabowski, a Harvard professor and prominent long-term care researcher, took to Twitter to push back on that claim, emphasizing that there’s “lots of work to do” and that the report was not intended to be an analysis of prior actions.

Michael Wasserman, a geriatrician and former CEO of major California nursing home operator Rockport Healthcare, wrote a long and thoughtful thread on Twitter critiquing the report, generally calling for CMS to issue direct orders instead of simple “guidance” on a variety of issues, from proper cohorting strategies to preventing unscrupulous nursing home operators from improperly diverting federal relief funding.

The diversity of the task force members was guaranteed to create debate and dissent: With commissioners ranging from PruittHealth CEO Neil Pruitt, Jr. to National Association of Health Care Assistants CEO Lori Porter to Justice in Aging directing attorney Eric Carlson to actual nursing home resident Penelope Ann Shaw, there was never going to be a complete alignment of opinion on how to fix the long-standing issues in nursing home care.

In fact, only 13 of the commission’s 25 members signed off on the report with a formal blanket endorsement, while 11 objected to certain portions — and Carlson declined to endorse the report at all.

Instead, Carlson issued a separate dissent in which he argued for CMS to focus solely on its strict statutory role of funding Medicare and Medicaid and enforcing regulations, dismissing for instance the notion of the federal government providing support for facilities without full-time infection preventionists as “fanciful.”

“Nursing homes have responsibility for training their own staff, with occasional assistance from federally funded Quality Improvement Organizations,” Carlson wrote. “For years, nursing home lobbyists have attempted to degrade this model.”

A single report with that roster of contributors was never going to include a rallying cry in one unified voice. But a single report was also never going to fix the systemic, chronic, and long-ignored problems that have plagued nursing homes, and the wider senior housing and care ecosystem, for decades.

What a single report can do is publicize the issues, provide a platform for criticism and advocacy, and hopefully light a fire under the people who can effect real change: lawmakers, government officials, and the industry itself.

What a single report can also do is provide safe cover for those who aren’t serious about making hard decisions that could upend the status quo for an entire industry — or daring to think about nursing home reform as something bigger, and more urgent, than the tired old playbook of papering over endemic problems with the short-term high of public outrage and a handful of new regulations that simply accept the reality of the current model instead of working to substantially change it.

We cannot let the latter scenario play out.

The public debate that we’ve seen over the last day is healthy and necessary. The conversations must continue long after this report becomes a footnote in the story of how COVID-19 laid bare the problems that had plagued the way America treats its seniors for decades.

If there’s one part of the report that I hope everyone, from every corner of this sector, can agree on, it’s this: “The time has come for a turning point in nursing home care. The Commission envisions a person-centered, resilient system of care that is better for the next generation — one that more deeply values and respects older adults and people with disabilities as vital to the fabric of American society.”

We can argue and differ, but as long as that principle sits at the center of the discourse, there’s a real chance for the devastation of COVID-19 to prompt real, permanent, and positive change for the swelling ranks of American seniors.

The choice is ours to make.