"Quality of life? To have a newspaper and a cup of hot coffee in the morning — decent coffee. But I'm just not able to get it." —Nursing home resident
"The resident council is a lifeline for resident support." — Nursing home resident
"We are not just people giving baths. We become someone's family, their friend. We learn about who they are, where they are from and who is important to them." —Certified nursing assistant (CNA)
When was the last time you went to a nursing home, either as a visitor, resident, legislator, provider or researcher? For many people, the answer is, "Never" or, "I can't remember."
The quotes above are a snapshot of feedback that the Moving Forward Nursing Home Quality Coalition1 — a national association focused on improving the quality of care and life in nursing homes — heard from nursing home residents, CNAs and others over the past year. Historically, nursing homes are often overlooked, misunderstood or not seen as a vital part of America's health care system. Nursing home residents often express a sense of social isolation and being disconnected from the greater community, an issue that has added stress to staff to take further measures to prevent this seclusion.2 With more than a million people living in more than 15,000 certified nursing facilities across the country, there is growing interest from the current administration, local leaders and the public to change this dynamic.3
IDENTIFIED WEAKNESSES AND OPPORTUNITIES
Many hold health care systems in high regard in terms of quality and reliability. However, health services research and government reports on nursing home quality over the years have identified weaknesses and opportunities to improve quality of life and safety for nursing home residents.4
As part of the National Academies of Sciences, Engineering and Medicine's 2022 report The National Imperative to Improve Nursing Home Quality, the report panel concluded, "… the way in which the United States finances, delivers and regulates care in nursing home settings is ineffective, inefficient, fragmented and unsustainable."5
In addition to the report, recent findings have further highlighted the need for adequate nurse (RN and LPN) and CNA staffing6; an enhanced nursing home survey/inspection process7; and other changes in nursing homes. Because these are complex, interrelated issues, approaches need to address them both individually and as a set.
One thing is certain: Nursing homes are people's homes. Individuals may live there for a few months to several years. In surveys conducted by the Institute for Healthcare Improvement, residents say they need more than just health care. Residents want to live in an environment that supports socialization and interactions that include staff members, others who care about them and activities and food that they enjoy.8\
MOVING FORWARD TO SIGNIFICANT CHANGE
So how can we collectively take action to bring forth meaningful change?
In line with its mission to make vital changes in policy and practice through the power of bringing diverse voices together, the Moving Forward Nursing Home Quality Coalition convened — starting in July 2022 — to review recommendations from the National Academies of Sciences, Engineering and Medicine's report. Its focus was to set forth actionable steps to improve nursing home quality while ensuring equity and cultural diversity.
Funded by The John A. Hartford Foundation, with additional support from Columbia University School of Nursing and the Johns Hopkins University School of Nursing, the coalition formed seven committees around seven priorities from the National Academies of Sciences, Engineering and Medicine's report, launched a website and built partnerships with federal and state leaders, nursing home providers, advocates and others.
Throughout these discussions, committee members asked themselves two questions: 1) What can be done in the next year? and 2) What is the most important thing within this category that we could accomplish?
Working committees developed and refined a total of nine action plans (see box on this page), including how to turn recommendations into meaningful and sustainable activities in nursing homes, cities, towns and local communities.
Some action plans focus primarily on practice changes — for example, how to ask individuals about their goals, preferences and priorities when they are admitted to the nursing home. Other plans focus on policy changes, such as increasing financial incentives for nursing home owners so that more nursing homes may convert to household or small home models.
The coalition has also begun working with multiple states (Pennsylvania, Michigan and others) to create or expand state-based teams focused on nursing home quality issues and opportunities. These teams will work closely with the national coalition to focus on each state's crucial nursing home and community issues, and how one or more of the nine action plans may be adopted or modified to meet the needs of nursing home residents and workers in that state.
GOING BEYOND THE DISCUSSIONS
These action plans give us new opportunities to bring additional individuals and organizations into the coalition and state teams, particularly as our work unfolds over the coming months. By reviewing these action plans, nursing home teams can explore how to get further involved in the national movement to improve quality of life for residents. Year 2 began in July, and the coalition's next steps are detailed in each action plan with goals, timelines and key partners.
Regardless of individual living situations, quality of life for nursing home residents is an issue that affects all of us. Most people will spend time in a nursing home during their life, or someone close to them will live in a nursing home at some point. Our nation must address long-overdue issues related to residents' quality of life, staff working conditions and finance reform. We must move beyond writing white papers and reports and take action in our local communities now.
The Moving Forward Nursing Home Quality Coalition holds regular webinars for anyone interested in learning more about the coalition and its action plans. To learn more about these webinars, visit https://movingforwardcoalition.org/taking-action/.
ALICE BONNER is chair of the Moving Forward Coalition and senior advisor for aging at the Institute for Healthcare Improvement. SUMIRE MAKI is program manager for the Moving Forward Coalition.
- Moving Forward Nursing Home Quality Coalition, https://movingforwardcoalition.org.
- Diana Lynn Woods et al., "Social Isolation and Nursing Leadership in Long-Term Care: Moving Forward after COVID-19," Nursing Clinics of North America 57, no. 2 (June 2022): 273–286, https://doi.org/10.1016/j.cnur.2022.02.009.
- "Providers & Service Use Indicators: Nursing Facilities," KFF, https://www.kff.org/state-category/providers-service-use/nursing-facilities/.
- Weiwen Ng et al., "Quality of Life Scores for Nursing Home Residents Are Stable over Time: Evidence from Minnesota," Journal of Aging & Social Policy 34, no. 5 (January 12, 2022): 755–768, https://doi.org/10.1080/08959420.2021.2022949; Christine A. Mueller et al., "Calling All Nurses—Now Is the Time to Take Action on Improving the Quality of Care in Nursing Homes," Nursing Outlook 71, no. 1 (January 2023): https://doi.org/10.1016/j.outlook.2022.11.001; Pi-lu Liu, Eilon Caspi, and Ching-Wei Cheng, "Complaints Matter: Seriousness of Elder Mistreatment Citations in Nursing Homes Nationwide," Journal of Applied Gerontology 41, no. 4 (September 4, 2021): 908–917, https://doi.org/10.1177/07334648211043063.
- National Academies of Sciences, Engineering, and Medicine et al., The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff (Washington, DC: National Academies Press, 2022).
- Dana B. Mukamel, Debra Saliba, and Heather Ladd, "Association of Staffing Instability with Quality of Nursing Home Care," JAMA Network Open 6, no. 1 (January 10, 2023): 2574-3805, https://doi.org/10.1001/jamanetworkopen.2022.50389; Eric Jutkowitz et al., "Effects of Nurse Staffing on Resident Outcomes in Nursing Homes: A Systematic Review," Journal of the American Medical Directors Association 24, no. 1 (January 2023): 75–81, https://doi.org/10.1016/j.jamda.2022.11.002.
- David G. Stevenson and Audrey K. Cheng, "Nursing Home Oversight during the COVID-19 Pandemic," Journal of the American Geriatrics Society 69, no. 4 (April 2021): 850–860, https://doi.org/10.1111/jgs.17047.
- "Age-Friendly Health Systems," Institute for Healthcare Improvement, https://ihi.org/agefriendly/.
Moving Forward's Nine Action Plans
The Moving Forward Coalition developed nine action plans drawing from particular challenges facing nursing homes, explained why they are important to residents' quality of life, defined focused goals to address those challenges and provided the steps the coalition will take to achieve them over a year. The plans relate to:
- Addressing residents' goals, preferences and priorities
- Strengthening resident councils
- Improving certified nursing assistant wages and support
- Expanding certified nursing assistant career pathways
- Enhancing surveyor training on person-centered care
- Designing a targeted nursing home recertification survey
- Increasing transparency and accountability of ownership data
- Developing a nursing home health information technology readiness guide
- Financing household models and physical plant improvements
Action plan details are at https://movingforwardcoalition.org/wp-content/uploads/2023/07/Action-Plans_Complete-Set.pdf.