Improve Quality

AARP asked experts to make recommendations on how to improve the quality of care at nursing homes. The systemic problems of the industry are complicated, as AARP reported in the December issue of the AARP Bulletin. However, we need to solve them before the next pandemic.

The AARP Bulletin spoke with dozens of experts. Here are 10 ways the long-term care industry can improve.

Goal: Make Environments Healthier

1. Require more registered nurses

Nursing homes with higher staffing levels of registered nurses (RNs) did better at controlling the coronavirus and reducing death, research from early in the pandemic shows. But federal laws and regulations only require nursing homes to employ an RN for eight consecutive hours a day. That can leave 16 hours with no RN coverage.

2. Partner with hospitals

Partnership helped prevent major outbreaks in nursing homes that could overwhelm emergency rooms. Hospitals can send rapid-response teams to assess outbreaks and assist care workers with infection control. It also provided telemedicine services. Nursing homes in the program have experienced lower rates of mortality and hospitalization than the national average.

3. Improve infection control

“Every nursing home should stockpile PPE, not just for this but for other kinds of contagious events that can happen,” says Patricia McGinnis, executive director of California Advocates for Nursing Home Reform. Advocates point out that it would save lives and lead to lower treatment costs.

4. Reduce isolation

“Social isolation has been a mental and physical health problem in nursing homes long before COVID-19,” says Bei Wu, director for research at the Hartford Institute for Geriatric Nursing at New York University. Lack of connection, Wu says, is associated with a litany of consequences, including a 50 percent higher risk of dementia, 29 percent higher risk of coronary heart disease events and 32 percent higher risk of stroke. “Any plan for improving nursing home quality of care has to address isolation,” she says.

A first step would expand virtual visits. Video chats with friends and family were associated with a 50 percent lower risk of depression compared with emails, social media or instant messaging, in a 2019 Oregon Health and Science University study of 1,424 older adults.

The next step is to create “safe rooms” for in-person visits. Those would include plexiglass walls, a sound system, antimicrobial surfaces and maybe even a “hug wall” made of flexible material for germ-free embraces.

Goal: Reexamine Business Approaches

5. Address the funding

Nursing home industry groups are lobbying for legislation adjusting Medicaid reimbursement rates to fund what they say are the actual costs of care. However, additional funding must be used to improve quality including redesigning nursing homes so they feel more like real homes and less like institutions.

6. Revamp the staffing model

A nursing home aide can be responsible for more than 20 residents on a shift. The job is physically and emotionally demanding, and lives can be at stake, yet the average wage is around $13 an hour.  But given the low-pay, high-stress nature of the work, there is a chronic shortage of workers. Without increased pay and benefits, nursing homes will remain short-staffed.

“We have seen during this outbreak that staffing is so stretched that they hardly have time to wash their hands and make sure their protective equipment is on properly,” she adds.

7. Improve oversight and reporting

The rules and regulations for operating a safe facility are detailed and unambiguous. However, the problem, advocates for nursing home residents say, is these laws and regulations are not strictly enforced.

New legislation aims to hold nursing homes more accountable. AARP supports, would “transform the oversight process for nursing homes that have consistently failed safety and care standards.”

8. Rethink ownership

About 70 percent of nursing homes are for profit, and many are part of large, complex and often opaque organizations.

“Regulate nursing homes like a utility so that we know exactly where the money goes,” says Charlene Harrington, professor emerita and a nursing home researcher at the University of California, San Francisco. “Only a certain amount could go for profits, and the rest would have to go for services.”

Even better would be ending the for-profit ownership model that dominates the industry especially the private-equity investment model of leveraging properties for siphoning funds.

Goal: Reshape the Industry

9. Provide more care at home

Innovative nursing home alternatives that have been cropping up across the U.S. are getting new attention as Americans question nursing homes as the default model of care. State programs that allow Medicaid funds for home care allowed more than 100,0000 people to move out of nursing homes between 2008 and 2019. Medicaid’s program, called Money Follows the Person, costs only about $882 million a year.

10. Create smaller nursing homes

Too often, nursing homes look, feel and function like hospitals. Susan Ryan, senior director of the Green House Project, says small, family-like households are a better option.

Green Houses are in 32 states. Just 10 to 12 residents live in a housing center and share an open kitchen, dining room and living room. Specially trained CNAs work exclusively in one house — making meals, doing laundry, socializing, helping residents pursue their interests and looking for early signs of health issues.