National Academies: US Nursing Home System Needs Fundamental Overhaul

The COVID-19 crisis publicly exposed systemic problems within the US nursing home system, where about 40% of deaths from SARS-CoV-2 infection occurred during the pandemic’s first year. Now, a major report provides a blueprint for overhauling what the authors concluded is an “ineffective, inefficient, fragmented, and unsustainable” approach to long-term and postacute care.

A committee of the National Academies of Sciences, Engineering, and Medicine released its lengthy consensus study report, The National Imperative to Improve Nursing Home Quality, in April. The panel found that the current system falls far short of its vision of high-quality nursing homes, in which “residents receive care in a safe environment that honors their values and preferences, addresses goals of care, promotes equity, and assesses benefits and risks of care and treatments.”

The authors recommend fundamental changes to how the US delivers, finances, regulates, and measures the quality of care in the nation’s nearly 15 600 nursing homes, which serve more than 1.3 million individuals. The panel emphasized that immediate action is needed to begin overhauling the troubled system, requiring a shared commitment from a number of federal agencies, state governments, nursing homes, providers, payers, researchers, and others.

The recommendations include improving low-paid nursing home workers’ wages and benefits while shoring up minimum staffing standards and education requirements. Nursing homes should be constructed or renovated to provide smaller and more home-like environments with single- rather than multiple-occupancy bedrooms and bathrooms, with ready access to personal protective equipment. Residents’ and their families’ experiences should be incorporated into enhanced quality measures in the Centers for Medicare & Medicaid Services (CMS) Care Compare website, where consumers can research facilities, for the first time. And studies should begin on a federal long-term care benefit.

To better prepare the workforce, the report calls for all health care professionals to receive geriatrics training, ideally with nursing home experience. The federal government should ensure that state agencies that conduct nursing home surveys have the resources they need to monitor facilities, investigate complaints, and enforce rules. Incentives should be created to increase adoption of electronic health records in nursing home facilities. Importantly, data on nursing homes’ often opaque finances, operations, and ownership should be collected, audited, and made publicly available.

Despite the vast scope of these and other changes detailed in the report, committee chair Betty R. Ferrell, PhD, MSN, CHPN, called the recommendations “very achievable” in an April briefing, noting that some could be implemented right away. “I can promise you that there is nothing in this 600-page report that any one of us would not want if it was us or someone we love about to go into a nursing home,” Ferrell, professor and chairperson of nursing research at City of Hope National Medical Center, said during the briefing.

Population estimates suggest that reforms can’t come soon enough. By the beginning of the next decade, about 1 in 5 people in the US will be aged 65 years or older and the number of people aged 85 years or older will grow from 6.7 million in 2020 to 9.1 million.

The National Academies study, sponsored by a coalition including the John A. Hartford Foundation, is the long-awaited follow-up to the landmark 1986 Institute of Medicine (IOM) report Improving the Quality of Care in Nursing Homes, which exposed a now-familiar array of problems including resident neglect and abuse, poor quality of life, high costs, and insufficient regulatory oversight. The Nursing Home Reform Act followed a year after the IOM report, leading to federal regulations and survey processes. Although other National Academies reports have addressed issues of geriatric care in the interim, the new study is the first comprehensive examination of nursing home care quality since the 1986 publication. It found that many of the concerns identified more than 35 years ago persist today.

Understaffing is a critical concern. “You really can’t have a conversation currently about nursing home care without talking about the workforce challenges that are being experienced,” geriatrician Suzanne Gillespie, MD, RD, CMD, a medical director in the VA Finger Lakes Healthcare System and president of the Society for Post-Acute and Long-Term Care Medicine, known as AMDA, said during an interview with JAMA. “This is something that we’ve seen over time and that the pandemic has illuminated.”

Nursing homes lost 241 000 employees from February 2020 to March 2022, about 15% of their total workforce, according to the American Health Care Association/National Center for Assisted Living (AHCA/NCAL). For David C. Grabowski, PhD, an author of the National Academies report and a professor of health care policy at Harvard Medical School, the attention the pandemic brought to understaffed nursing homes offers an unprecedented opportunity to mandate improvements. “I think there’s a momentum that we haven’t had previously towards this objective,” he said during the April report briefing.

Keeping nursing homes sufficiently staffed with well-prepared and empowered employees will require a number of changes in tandem, the report suggests, such as ensuring competitive wages and benefits—including health insurance, childcare, and sick pay—and providing certified nursing assistants (CNAs) with free entry-level training and continuing education, as well as career advancement opportunities.

The report tasks CMS with enhancing the current nursing home minimum staffing requirements to include a direct-care registered nurse on site at all times, a full-time social worker, and an infection control specialist who is a registered nurse or physician and works a sufficient number of hours to meet the facility’s needs. The agency also should strengthen education requirements for nursing home staff. CNA certification should require more training hours, for example, and medical directors should have training specific to older adult care and certification in infection control and prevention.

The AHCA/NCAL and LeadingAge, an organization that represents nonprofit nursing homes and other aging services, agree that the worker shortage must be urgently addressed. But the groups say that increased funding and reimbursements are key to realizing the report’s broad recommendations.

“Medicaid, the dominant payer of long-term care services, doesn’t fully cover nursing homes’ costs—especially the cost of providing quality care,” a LeadingAge spokesperson wrote in an email to JAMA. “Regulations and enforcement, even with the best intentions, just can’t change that math.”

An emailed statement from AHCA/NCAL expressed similar concerns: “We fully support preparing for emergencies as well as transparency and accountability—what we cannot support are unfunded mandates that will not solve systemic challenges or help improve resident care, but rather will compromise access to care.”

The new recommendations have at least 2 obvious funding streams: better allocation of finances toward staffing and clinical bedside care and more appropriate payment for the type of care that occurs in nursing homes, said Gillespie, who is an associate professor of medicine in the Division of Geriatrics and Aging at the University of Rochester School of Medicine and Dentistry. “When you look at the individuals that are in nursing home care today vs 20 years ago, the complexity of care is much greater,” she said. “We need to make sure that our financial reimbursement models capture that appropriately.”

Increased transparency and accountability could help free up dollars for much-needed industry improvements, Harvard’s Grabowski noted in an email. Research cited in the report suggests that for-profit nursing homes, which Grabowski said represent about two-thirds of the industry, generally deliver lower-quality care than not-for-profit and government-owned facilities. What’s more, residents in private equity–acquired facilities fare worse than those in other for-profit nursing homes.

The report catalogs several ways that unscrupulous owners and operators cook the books to boost profits. In one widespread practice, owners outsource goods and services to their other companies at inflated prices, siphoning off dollars that could be spent on staff and residents.

The report also details how private equity investors and real estate investment trusts (REITs) have made nursing home ownership increasingly complex, allowing owners to hide money while claiming narrow profit margins. During his State of the Union Address in March, President Joe Biden pledged to take on these financial forces: “[A]s Wall Street firms take over more nursing homes, quality in those homes has gone down and costs have gone up. That ends on my watch.”

Although CMS requires nursing homes to report ownership structures, the National Academies committee found that the data are incomplete, are not audited for accuracy, and can be difficult to parse. More detailed publicly available information about who owns nursing homes and how the entities spend funds—much of it from taxpayer-derived Medicaid and Medicare reimbursements—is expected to redirect money back to staff and residents.

Gillespie said the report is only the beginning. “For each of the recommendations that’s made here, we need to create the opportunities for our policy leaders, for our scholars in nursing home work, for our interdisciplinary teams and facilities to actually work together to get the recommendations accomplished,” she said. “That’s the piece that we need to pick up this big tome of work and actually make it live.”

Some initiatives are already under way. Earlier this year, CMS began posting nursing homes’ staff turnover rates and weekend staff levels on the Care Compare website. Those data will factor into the facilities’ star ratings as of this July. CMS said it expects to issue proposed rules for nursing home minimum staffing level requirements next year.

The White House in February announced a set of nursing home reforms that, among other goals, will reduce room occupancy, increase funding for health and safety inspections, and recruit and retain workers by offering pathways to becoming registered or licensed nurses. The reforms also will crack down on “predatory owners and operators who seek to maximize their profits at the expense of vulnerable residents’ health and safety,” according to the announcement. CMS will collect and publicly report detailed ownership and operating data, while the US Department of Health and Human Services and other agencies will scrutinize the role of private equity and REITs in the nursing home industry.

“The Biden reforms are a strong start and very consistent with the recommendations offered in the National Academies report,” Grabowski wrote in his email. “However,” he noted, “we need to think bigger. The full package of recommendations outlined by the National Academies are an opportunity to transform nursing home care in America.”