Nursing homes in desperate need of giant overhaul, experts say

academies-300x90The nation’s nursing homes and other long-term care facilities are in dire need of drastic overhaul to dramatically improve the quality and safety of their treatment of the aged, sick, and disabled. They too often now get what one expert has described as “ineffective, inefficient, inequitable, fragmented, and unsustainable” care.

To repair the glaring, longstanding wrongs in these facilities — problems that critics say contributed to 150,000 resident deaths during the coronavirus pandemic — requires sweeping practical, regulatory, and financial changes in an industry focused on profits and resistant to change, according to newly published expert research report by the National Academies of Sciences, Engineering, and Medicine.

The academies, with members who are leaders in their fields, are private, nonprofit institutions that work outside of government to provide objective advice on matters of science, technology, and health.

Not too much to ask?

They slammed the nursing home industry in a 1986 report and called for major reforms, some of which have been put in place. Alas, as the pandemic showed, long-term care in the country has not gotten better, and, instead, has become a nightmare that requires urgent response, especially as the nation grays. As the academies’ latest report pointedly inquires:

 “Is it too much to ask that each and every resident in every nursing home receives care that includes high-quality physical care, behavioral health, safety, and psychological support? Is it too much to ask for a plan of care to establish what is most needed for each resident to receive high-quality care that is truly person-centered? Are we too bold to recommend on-site registered nurse coverage in nursing homes, a social worker, and an infection control specialist?

“After all that we have witnessed during the Covid-19 pandemic, is it too much to ask that nursing assistants are better trained to deliver care to often frail people with limited social support or resources in the last years of their lives? It is not too much to ask that all residents receive good-quality care regardless of race, ethnicity, or geographic location? In fact, the recommendations in this report are no more than what any one of us would want for ourselves or for those we love if we or they were in a nursing home. How can we not accept the committee’s recommendations and profoundly change the delivery of care in U.S. nursing homes?”

The Associated Press reported this of the academies’ recommendations:

“The report covers a vast cross-section of long-term care, from granular details such as the way facilities are designed to foundational issues that would require massive political capital and investment to address. Among them: the authors advocate for creating a new national long-term care system that would exist outside of Medicaid, the program that is at the center of most long-term care financing. The likelihood of such a proposal successfully winding its way through Congress seems low in the current political climate … ”

In practical terms, the experts called for better trained, higher paid health staff — not only with minimum nursing standards but also for front-line aides who provide the tough, demanding daily care for most residents. The staffers and the facilities themselves must get  better and more rigorous oversight, with heightened inspections and improved measurements of the safety and quality in homes.

The 17 expert members of the academies’ panel noted that money plays a huge part in every public policy conversation about long-term care — and the industry must make its finances far more transparent, so residents, their loved ones, taxpayers, regulators, and lawmakers can fairly judge how the huge sums that go to facilities is correctly spent.

Industry pushes back, insists it needs more U.S. funding

Industry officials replied to this critical study as they have when assailed during the pandemic: We’re doing the best we can, and, if residents and others want better and more care, someone — ahem, mostly we taxpayers — needs to foot the bill.

Lest anyone think that’s a simplistic or cynical view of industry answers to calls for reform, just look at the shoving back that the Biden Administration is getting from owners and operators of nursing homes and other long-term care facilities over proposals to deal with staffing shortfalls — in training, care, and in plain old numbers.

NPR reported that facilities across the country are howling that they cannot find the people they need, and they are battling tooth-and-nail the administration plans to order improvements in this area. The broadcast report contains good details on the administration crackdown, how it affects residents, and industry opposition. But focus, please, on a few paragraphs about health staff turnover in the District of Columbia, which has adopted staffing minimums, and the comments from Tina Sandri, CEO of a nursing home:

 “’In D.C., you can work for Amazon at $19 an hour. You can be a dog walker for $18 an hour,’ she says. Sandri struggles to get certified nursing assistants, who typically start at $15.20 an hour, in the door. Four out of 5 who initially express interest in a job don’t come in for interviews. As a nonprofit, [the home she runs] doesn’t have the bandwidth to raise wages, Sandri says. Like most nursing homes in the U.S., it relies on Medicare and Medicaid for most of its funding. Unless the government increases the amount it pays for nursing home care, Sandri says, ‘we just don’t have it in our piggy bank.’ To meet Washington, D.C.’s staffing requirements, she has been working her staff ‘to the bones … They’re tired. They’re burned out. They’re physically exhausted, and even committed people in this industry will turn around and say, “I don’t know how much longer I can do this,” says Sandri.”

Not good. In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them and their loved ones by neglect and abuse in nursing homes and other long-term care facilities.

The pandemic laid bare the increasing failures in the long-term care industry, and, while coronavirus deaths in facilities are hitting new lows, too many residents and loved ones still struggle with the tough choice of potentially pursuing justice and remedies in the civil system for unacceptable wrongs in nursing home care.

The administration has taken important steps to deal with a profoundly troubled industry, which itself is riven among under-funded, charitable enterprises and investor-owned (yes, by those notorious hedge funds), profit-ravenous outfits that are significant and rising part of this crucial component of the U.S. health care system. All the facilities go on, and many thrive, by putting their hands deep into taxpayers’ pockets, arguing that if we don’t cough up gobs of more cash, then the most vulnerable among us will suffer — yet more. Really? By the way, don’t overlook that experts estimated in 2017 that more than half of us will spend some time in a nursing home or long-term care facility.

Not just quality of care but also quality of life

As the AP reported of the academies’ calls for reform, quoting David Grabowski, a nursing home expert, Harvard Medical School professor, and study participant:

“Among the more routine subjects in the report, but one that nonetheless impacts residents’ everyday lives, the authors call for homes to prioritize private rooms and bathrooms instead of the communal ones that can fuel infections and underscore the institutional setting. And in a blunt reminder of how bleak life in nursing homes can be, the report notes most residents spend ‘little if any time outdoors,’ calling for facilities to make outside access more accessible. The proposals, Grabowski said, have the potential to improve the days of residents who, even when they are having their basic medical needs met, are frequently lacking in other areas of their lives. ‘I think the average nursing home resident has an OK quality of care but a poor quality of life,’ Grabowski said.”

We have much work to do to ensure that the elderly, sick, and disabled are not doomed to unsafe, unhealthy institutional warehouses in their debilitated days, especially if we pay for this grim care out of the national treasuries. It isn’t anything we would want for ourselves, or our loved ones, and the reformers are right that we must take action, if nothing else to advance and protect our own interests.

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