Noting that the devastating impact of the pandemic on nursing home residents and staff has renewed attention to the long-standing weaknesses that impede the provision of high-quality nursing home care, a National Academies of Sciences, Engineering, and Medicine (NASEM) committee has proposed major changes to the way the United States finances and measures the quality of nursing home care.
NASEM’s 17-member Committee on the Quality of Care in Nursing Homes’ report, “The National Imperative to Improve Nursing Home Quality,” was funded by The John A. Hartford Foundation, the Commonwealth Fund, the Sephardic Foundation on Aging and the Fan Fox and Leslie R. Samuels Foundation. It notes that the way in which the United States finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, fragmented, and unsustainable, and that immediate action to initiate fundamental change is necessary.
Among its recommendations are that the U.S. Department of Health & Human Services should study the establishment of a federal long-term care benefit.
An April 6 webinar introducing the report included committee member David Grabowski, Ph.D., a professor in the Department of Health Care Policy at Harvard Medical School.
Grabowski said a key goal is to create a more rational and robust funding process. Currently, the financing approach to nursing care is highly fragmented. “The federal/state Medicaid program plays a dominant role as a payer of long-stay nursing home care, but is constantly subject to state budget constraints. The federal Medicare program only covers short stay post-acute care in nursing homes,” he said. The fragmented financing system leads nursing homes to rely on higher payments for Medicare services to cross-subsidize lower Medicaid payments. This is an inefficient and unsustainable arrangement, Grabowski noted.
Services such as hospice care are paid separately, and not well integrated into standard nursing home care. Private insurance coverage for long-term care is limited, and relatively few people can afford to pay out of pocket for an extended nursing home stay. “To address these significant shortcomings, the report includes a recommendation about moving toward a federal long-term care benefit by studying how to design such a benefit, and then implementing state demonstration programs to test the model prior to national implementation,” Grabowski said.
For short-stay post-acute nursing home care, the committee calls for extending current bundled payment arrangements to all conditions to advance value-based payment based on quality, not quantity of services. Additionally, the committee recommends demonstration projects to explore the use of alternative payment models for long-term nursing home care, separate from the bundled payment initiatives for short stay post-acute care.
Improving quality measurement
Marilyn Rantz, Ph.D., R.N., an expert in quality measurement in nursing homes and an emeritus professor in the Sinclair School of Nursing at the University of Missouri, spoke about ways to improve quality measure reporting. The CMS website Care Compare provides data on the quality of nursing homes. However, many key indicators of high-quality care are missing, and several improvements are needed to enhance the quality of the imported data, she said. The committee recommends adding several measures to Care compare, including measures of resident and family experience. Additionally, she added, more work is needed to develop valid measures for key domains of quality, including palliative and end-of-life care, staff satisfaction, psychosocial and behavioral health, and various structural measures.
“The quality of nursing home care is particularly concerning for several high-risk populations, who experience significant disparities in care. However, the lack of robust data makes it difficult to document the true extent and impact of disparities in care,” Rantz said. Noting the tragically disproportionate results of people of color dying in nursing homes during the COVID pandemic, the committee recommends the development of an overall health equity strategy for nursing homes, which include a minimum data set, a national report card, culturally tailored interventions, and policies and strategies to identify and address disparities.
Another goal relates to the deployment of health information technology in all nursing homes. Health IT can help personalize care, she noted. Nurses can specify individualized plans of care so that nursing assistants can assure approaches to each individual in terms of what they not only want, but need. Health IT increases efficiency in care delivery, enhances care coordination, improves staff productivity, promotes patient safety and reduces health disparities, she said. “Residents often have complex needs that require care coordination across multiple care settings, further underscoring the need for nursing homes to have EHRs that communicate with other systems to ensure smooth, accurate transfer of clinical information and safe care transition. Previous federal programs provided incentives to certain healthcare professionals in hospitals to support EHR adoption. Nursing homes were not eligible for such incentives. The committee recommends identifying pathways to provide financial incentives to nursing homes for adoption of certified EHRs.”
'Radical transformation' is needed
“This is an important moment for older adults and the people who care for them. As the past two years have made plain, we need comprehensive and profound change to improve America’s nursing homes,” said Terry Fulmer, Ph.D., R.N., president of the John A. Hartford Foundation, in a statement. “A radical transformation is needed to make them places that consistently provide safe, high-quality care, and a setting where people want to live and work.
Fulmer added that this NASEM study provides a clear path to guide the transformation that is needed. “It has been more than 35 years since the last large-scale report assessed nursing home challenges, and as COVID-19 demonstrated, the need for reform is urgent and undeniable. “This report offers seven goals with actionable recommendations to bolster the nursing home workforce, enhance quality and equity and ensure that what matters most to nursing home residents and their families is respected. Everyone wants excellence in long-term care for our families, friends and ourselves. This report shows the way. Legislators, regulators and community leaders must follow it to keep the promise of better care for those who live and work in nursing homes.”
