JULIE TROCCHIO, BSN, MS

There is no doubt that COVID-19 was devastating in long-term care facilities with significant sickness, hospitalization and even death among staff and residents. Why? One reason is that most nursing home residents are over 80 and have multiple preexisting conditions. In addition, nursing home leaders point out that the federal help to nursing homes was late and insufficient. They were among the last to get personal protective equipment (PPE) and information about how to fight the disease. While some blamed poor quality in nursing homes, research eventually revealed that the volume of COVID in nursing homes actually mirrored the rate of the virus in communities: when it was in communities, it was in its nursing homes.¹

As the pandemic receded, two efforts were announced to improve nursing home quality and to prevent the COVID experience from being repeated. A fact sheet released earlier this year by the White House, called "Protecting Seniors by Improving Safety and Quality of Care in the Nation's Nursing Homes,"² revealed how the federal government — through regulation and policy changes — intends to address nursing home quality. Soon after, the National Academies of Sciences, Engineering, and Medicine published the results of its study, The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff.³ Both efforts are aimed at setting the path forward to reform our nation's nursing home care.

FEDERAL PROPOSALS
During this year's State of the Union address, President Joe Biden announced that he will be proposing a set of nursing home reforms for the Department of Health and Human Services (HHS) and its Centers for Medicare and Medicaid Services (CMS) to implement. These were outlined in the White House fact sheet related to nursing home safety and quality of care, which stated:

"The pandemic has highlighted the tragic impact of substandard conditions at nursing homes, which are home to many of our most at-risk community members. More than 1.4 million people live in over 15,500 Medicare- and Medicaid-certified nursing homes across the nation. In the past two years, more than 200,000 residents and staff in nursing homes have died from COVID-19 — nearly a quarter of all COVID-19 deaths in the United States."⁴  

The federal reforms proposed are aimed at improving the quality and safety of nursing home care, enhancing oversight and accountability, and making facility ownership more transparent.

Improving Care
Four new initiatives are directed at improving quality care. First, HHS will study the adequacy of nursing staffing and consider strengthening minimum staffing levels. (Currently, some states go beyond the federal staffing requirements of providing 24-hour licensed nursing services. The federal government is considering stronger RN staffing requirements.) Second, there will be efforts to reduce what the administration calls "resident crowding," which can lead to increased risk of contracting infectious diseases, such as COVID-19. Third, HHS will strengthen its skilled nursing value-based purchasing program, adding metrics such as weekend staffing and turnover. There might be higher reimbursement from the government for nursing homes that meet some additional quality measures. A fourth initiative will be aimed at reducing the use of antipsychotic drugs in nursing homes in order to bring down the inappropriate use of antipsychotic medications.⁵

Enhancing Oversight
The administration plans to strengthen its compliance program with additional funding for inspections and imposing new penalties on poor performers. It will ask Congress to provide an increase of nearly 25% for nursing home health and safety inspections.

To address the issue of the poorest performers, CMS will strengthen its Special Focus Facility Program, which identifies and increases scrutiny of problem facilities. It will also add new financial penalties and other sanctions and will ask Congress to raise the dollar limit on penalties from $21,000 to $1 million.

More Transparency
In announcing the nursing home reform proposals, the White House expressed concern that corporate owners have not been accountable for poor performance. As a result, CMS will create a database registry of owners and operators to give states and the public information about the violation history of these companies. The administration also plans to examine the role of private equity in nursing home ownership.

NATIONAL ACADEMIES OF SCIENCES, ENGINEERING, AND MEDICINE STUDY
The National Academies of Sciences, Engineering, and Medicine convened an expert panel to examine how to improve nursing home quality with an emphasis on challenges that have arisen in light of the COVID-19 pandemic. Noted earlier, its report, The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff, concludes that the way our nation finances, delivers and regulates care in nursing homes is inefficient, fragmented and unsustainable. The report calls for immediate action to initiate fundamental change, and identifies seven broad goals for improving quality care in nursing homes. These objectives concern person-centered care that ensures the health, quality of life and safety of nursing homes residents; a well-prepared workforce; increased transparency of nursing home finances, operations and ownership; a more rational financing system; an improved quality assurance system; additional quality measures; and improved health information technology.⁶

Improved Quality of Care, Life and Safety
In the area of improving care, quality of life and safety, the report recommends more government oversight to ensure that the priorities of residents and their families are included in decision-making. It also recommends greater attention to nursing homes in disaster preparedness and response.

Workforce/Staffing
On workforce, the study said that current staffing requirements need to be enhanced. It calls for 24-hour RN coverage, a full-time social worker with a social work degree and an RN or physician infection prevention and control specialist. It urges that there be opportunities for certified nursing assistants to have career advancement and mentoring, in addition to more education and training for all staff.

Transparency
In calls for more transparency, the report says the HHS should collect, audit and make public detailed facility data on operations and ownership. It also asks the government to assess the impact of nursing home real estate ownership models on the delivery of quality care.

Financing: Adding a Federal Benefit
While funding for long-term care financing has been the subject of numerous studies and reports, the committee called for yet another study of how to finance long-term care. Noting that the current approach to financing nursing home care is fragmented, the report says that quality nursing home care needs a more stable system of financing. It urges changes in both Medicare and Medicaid payments. It also says that while enacting a new long-term care benefit will be politically challenging, a federal benefit has the most potential to increase access, reduce unmet need and reduce inequities in access by guaranteeing that payments are adequate to cover quality care.

Continuous Quality, Better Measures and Health IT
In another goal for nursing home quality as it relates to continuous quality, the report says CMS must make sure that state survey agencies have the resources they need and should study how to make the survey system more efficient. For example, there could be modified oversight of high-performing facilities and more robust oversight of poor performers.

Additional goals relate to the need for better quality measures and information technology. The report says quality data should be collected by independent reviewers and that there should be more and better publicly reported measures. On technology, the report says there should be incentives for nursing homes to adopt electronic health records.

CONCLUSION
The quality and oversight of America's nursing homes grabbed the attention of researchers, policymakers and the public as vulnerabilities were unveiled during the pandemic. With the country's booming aging population and as the need for aging services continues to grow, the timing could be right for the recommendations of these two initiatives to change the long-term care landscape for the better.

JULIE TROCCHIO, BSN, MS, is senior director of community benefit and continuing care for the Catholic Health Association, Washington, D.C.

NOTES

1. David C. Grabowski, R. Tamara Konetzka, and Vincent Mor, "We Can't Protect Nursing Homes from COVID-19 Without Protecting Everyone," The Washington Post, June 25, 2020, https://www.washingtonpost.com/opinions/2020/06/25/we-cant-protect-nursing-homes-covid-19-without-protecting-everyone/.
2. "FACT SHEET: Protecting Seniors by Improving Safety and Quality of Care in the Nation's Nursing Homes," The White House, February 28, 2022, https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/.
3. National Academies of Sciences, Engineering, and Medicine, The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff (Washington, DC: The National Academies Press, 2022).
4. "Protecting Seniors by Improving Safety," The White House.
5. "Monitoring Psychotropic Drug Use in Nursing Homes," Office of Inspector General: U.S. Department of Health & Human Services, https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000470.asp.
6. "Recommendations: The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff," National Academies of Sciences, Engineering, and Medicine, April 2022, https://nap.nationalacademies.org/resource/26526/Nursing_Homes_Recommendations.pdf.