Impact of COVID In Nursing Homes

Problems We’ve Ignored for Too Long: A Hearing on the Impact of COVID In Nursing Homes

“COVID completely devastated nursing homes in the U.S.”

Dr. David Grabowski, a professor of health care policy at Harvard Medical School, and a Nexus Fellow, made this statement before a House subcommittee hearing on the impact of the coronavirus in our nation’s nursing homes.

Among the staggering statistics Grabowski shared with the subcommittee:

  • There were more than 1.2 million cases of COVID among nursing home residents, which led to roughly 172,000 COVID-related fatalities.
  • More than 2,600 nursing home staff members died from COVID, “making nursing home workers the most dangerous job in America.”
  • In the aftermath, both resident census levels and staff employment levels were down by more than 10% from pre-pandemic levels.

Drawing on his research, as well as his work on a commission with the National Academies of Sciences, Engineering, and Medicine, Grabowski made recommendations for reform to improve the situation for caregivers and residents going forward.

Grabowski urged policymakers to take a system-level approach to policy reforms to protect residents and caregivers. He emphasized that it is not too late. “We have an incredible opportunity right now to address problems that we have ignored for far too long.”

He proposed recommendations for short-run policies in two areas:

  1. Increase vaccination levels
    1. Extend the federal vaccine mandate for nursing home staff to include booster doses. Currently, only about half of all staff are fully vaccinated.
    2. Provide federally supported vaccination clinics for facilities with lower booster vaccine rates for staff and residents, to ensure that residents and staff have access to a vaccine clinic.
  2. Improve staffing
    1. Introduce a federal minimum staffing standard
    2. Increase staff pay and benefits
    3. Provide opportunities for career advancement
    4. Create a better work environment

“The way the U.S. finances and regulates care in nursing home settings is ineffective, inefficient, fragmented and unsustainable.” – David Grabowski

As a move towards a federal long-term care benefit, Grabowski suggested an approach for locally testing and creating benefit implementation with established criteria to evaluate success. He also emphasized the importance of accurate financial information to ensure payments are adequate to cover comprehensive nursing home care. In addition, value-based nursing home payment models should be created to reward facilities for providing better quality.

Additional panel members of the expert witnesses testifying before the House subcommittee included: Alice Bonner PhD, RN, FAAN; Adelina Ramos, Certified Nursing Assistant and 1199NE member, from Greenville, RI; and Jasmine Travers, AGPCNP-BC CCRN PhD RN, Assistant Professor of Nursing, NYU Rory Meyers College of Nursing.

See a video of the full hearing:

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Long Term Care Staffing Shortages

The Solution for Long-Term Care Staffing Shortages? Innovative Immigration Policies

Who will care for aging baby boomers? This was the question posed to an expert panel at an event that explored the links between immigration policy and long-term care policy. The online event was hosted by the Center on Children and Families of the Brookings Institute. It brought together leading researchers to present their findings on the role of immigration in caregiving, and to discuss the country’s caregiving needs, and policies to help address them.

Highlights of the discussion included:

  • The link between increased immigration and the increased support available for aging in place.
  • Economic benefits to family caregivers from larger labor pools supported by increased immigration.
  • Improved quality of care that results from a larger labor force and increased immigrant labor.

Anne Tumlinson, CEO of ATI Advisory and a Nexus Fellow, was on hand to provide her analysis of the policy landscape. She pointed to the severe economic impacts experienced by families and family caregivers that results from the lack of a national long-term care system in the United States.

Other challenges raised during the forum include the persistently low wages in the caregiving industry, enormous gaps in Medicare coverage for needed services for older adults, confusing variation by state of the types of services covered by Medicaid, and the difficulties that arise in addressing changing labor needs caused by inflexibility in employment-based channels for legal migration.

Possible solutions proposed included:

  • Addressing the inflexibility in the employment-based channels for legal immigration, to help address shortages and changing caregiving labor needs.
  • Creation of a national long-term care system to serve American families equitably and prevent financial hardships for families caring for loved ones.
  • Reallocating resources to address the persistent low wages in the caregiving industry, and to help create incentives for caregivers to remain in the field.

Read more at Brookings.
View the full discussion.

 

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Housing For Middle-Income Seniors

Middle-Income Seniors – The Forgotten Middle

When it comes to senior housing, wealthy seniors can pay their own way and low-income seniors often qualify for Medicaid. The real problem is for those in the middle. They aren’t wealthy enough for private pay, yet they are too well-off for Medicaid. To make matters worse, the number of people stuck in the middle will nearly double over the next decade. Senior housing operators and policymakers have the opportunity to serve this new market, but how and to what extent?

Nexus founder and Fellow Bob Kramer discusses “The Forgotten Middle” with Nexus Fellow Caroline Pearson, senior vice president health care strategy, NORC at the University of Chicago in an episode of Foresight TV hosted by Steve Moran of Senior Living Foresight.

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Relief ahead for health care worker burnout

Relief Ahead: HHS Funds 3-Year Program to Reduce Health Care Worker Burnout

Another cost of the COVID-19 pandemic? Caregiver burnout. Research firm Activated Insights conducted a two-year survey of 330 senior living and care workers. The results? “Worker burnout increased substantially during the pandemic at independent living, assisted living, memory care and skilled nursing facilities,” according to a report by McKnight’s Senior Living.

One of the surprising findings is that burnout declined by 12% for home care workers.

In a conversation with McKnight’s Home Care Daily. Activated Insights CEO and Nexus Fellow Jacquelyn Kung suggested an explanation for the decline. Home care agencies “have adapted very quickly and are supporting their employees a lot more than they have in the past.”

The good news? The U.S. Department of Health and Human Services (HHS) has announced $103 million in funding for a three-year program to Strengthen Resiliency and battle worker Burnout.

“Worker burnout increased substantially during the pandemic at independent living, assisted living, memory care and skilled nursing facilities.”

“It is essential that we provide behavioral health resources for our healthcare providers — from paraprofessional to public safety officers, so that they can continue to deliver quality care to our most vulnerable communities,” HHS Secretary Xavier Becerra said in the announcement.

The McKnight’s report went on to say, “In awarding the money, HHS said healthcare providers face many challenges and stresses due to high patient volumes, long hours and workplace demands during normal time. During the pandemic, those challenges were amplified and had a disproportionate impact on rural communities and communities of color.”

Read the full article.

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ATI Analysis of Medicare Population Needs and the Critical Role of LTC Pharmacy

As many as 70 percent of individuals who reach age 65 will experience severe long-term-care (LTC) needs before they die. Those needs might range from help with managing their finances or medications, to help bathing and getting dressed. Having LTC needs does not necessarily correspond to living in a long-term care facility, however. Instead, people with LTC needs may live and receive services at home or in other community-based settings.

Unfortunately for those living outside of LTC facilities, they face barriers to getting the assistance they need. A study conducted by ATI Advisory, in partnership with the Senior Care Pharmacy Coalition (SCPC), found that “state and federal policy and health plan requirements can create barriers that restrict people aging outside facility settings from accessing long-term services and supports, including LTC pharmacy.”

As a population with high prescription drug utilization, access to LTC pharmacy is especially important to Medicare beneficiaries with LTC needs. The study found, however, that despite the pivotal role that LTC pharmacies play in the care of those with LTC needs, this role is not widely understood or acknowledged by individuals, caregivers, policymakers, and payers.

Moreover, the study found that Medicare beneficiaries with LTC needs are demographically different from those without LTC needs in several important ways. The population studied was statistically “more likely to be Black or Latinx, female, dually eligible for Medicaid, clinically complex, and have higher healthcare and prescription drug utilization than beneficiaries without LTC needs.” Addressing the barriers to access to LTC services is necessary to work toward parity in access to services, coverage for services, support for caregivers, and equity in outcomes.

Read the study outcomes.

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long-term care infrastructure op-ed in The Hill

America’s long-term care infrastructure: A road to nowhere – Op-ed in the Hill co-authored by Nexus Insights

In a recent op-ed in The Hill, Nexus Insights Fellows Anne Tumlinson, David Grabowski and Robert Kramer, raise an important point that has been missing from recent discussions around transforming long-term care following the pandemic. The Biden Administration has proposed a $400B investment in home- and community-based services (HCBS). We assert this investment is necessary but not sufficient. Without additional spending on services to help families navigate and manage long-term care services, this HCBS investment is basically a “road to nowhere.” We argue for the need to create a network of long-term care service hubs across the country to help families navigate services.

As you know, there have been A LOT of thought pieces around improving long-term care going forward, but we have not seen this point made elsewhere. Thus, we believe it would be an ideal time to make this point as policymakers consider the Biden proposal.

Excerpt:

Long-term care is complex. Few Americans plan ahead and most wait until a crisis pushes them into a frantic search for solutions. It doesn’t have to be this way.

Every day older adults lose their ability to care for themselves. Often, they are discharged from the hospital too weak or confused to be left alone or care for themselves. Now what? Who will take care of them? Is home- or facility-based care the best option? How much will it cost and who will pay? Does Medicare cover it? Does Medicaid? If home care is the answer, how do you find a qualified and affordable caregiver? Where do you even start? Life-changing decisions must be made, and fast.

Read the full op-ed in The Hill.

Anne Tumlinson is CEO of ATI Advisory and the Founder of Daughterhood. David Grabowski is Professor in the Department of Health Care Policy, Harvard Medical School. Robert Kramer is the founder of Nexus Insights, and the co-founder and Strategic Advisor & former CEO of the National Investment Center for Seniors Housing & Care (NIC).

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David Grabowski presents a podcast on rethinking long-term care

Grabowski Spotlighted on Disrupt Podcast: Rethinking Long-Term Care in the US

The nation’s infrastructure has become a hot topic, as the Biden administration lays out its infrastructure plan. Long-term care for the growing senior population is one of the areas for proposed investment, which may be a surprise to some, but not to those in the industry. Rethinking long-term care for our nation’s rapidly aging population is an urgent problem, but addressing it effectively is a complex one.

David Grabowski, Professor of Health Care Policy at Harvard Medical School and a Nexus Insights Fellow, was interviewed recently on his thoughts and recommendations for the reformation of long-term care in the United States. Grabowski is a key figure in the research, policy and media world, with expertise in the economics of aging, Medicare, and the integration and coordination of care for dually-eligible beneficiaries. He’s a member of the Medicare Payment Advisory Commission (MEDPAC), a well-known expert in the post-acute care services realm and a leading speaker on industry publications and newscasts around the world.

Grabowski’s recommendations range from a unified post-acute payment system to changing up the traditional nursing home model and investing more heavily in home-based care. He compares the United States to other developed countries for home and community-based services spending, considers why investment in nursing homes and home care services is not an either-or proposition, and explores the future of SNF-at-home programs.

Listen to Grabowski’s Interview: A part of the Home Health Care News podcast series Disrupt.

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Bob Kramer and Anne Tumlinson discuss HCBS

Foresight TV: Bob Kramer & Anne Tumlinson – What Does HCBS Mean For LTC?

With the federal government considering an investment in the country’s infrastructure, a new light has been shed on the importance of infrastructure. And from the resulting discussion, a broader understanding of what is vital infrastructure is emerging. That infrastructure necessarily includes a system of long-term care for the nation’s aging population and a trained workforce to deliver that care.

“We have an outdated, crumbling infrastructure in nursing homes. We have non-existent infrastructure in home and community-based services (HCBS). And we have millions of older adults living longer, many of whom will need services and supports,” said Bob Kramer, Founder and Fellow for Nexus Insights, and Co-Founder and Strategic Advisor for the National Investment Center for Seniors Housing & Care (NIC).

Kramer recently interviewed long-term care expert Anne Tumlinson about the importance of long-term care and changes needed in how it’s delivered and how it’s paid for. Tumlinson, the Founder and CEO of ATI Advisory, and Founder of daughterhood.org, offered recommendations for the policy changes needed to make long-term care financially viable for more seniors and their families. Her recommendations also addressed the critical need for a living wage for the shrinking pool of caregivers who work in long-term care, and the important role of HCBS in helping seniors thrive.

“We don’t have a system; instead, every single family has to create their own system, over and over again. What is out there that could help me? How do I find it, set it up, coordinate it? There is currently no system or function in our society to handle that,“ said Tumlinson.

The interview was hosted by Senior Living Foresight. View the entire discussion.

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LTSS caregiver and patient

ATI Advisory Issues Recommendations for Expanding Access to Home and Community-Based Services

Long-term services and supports (LTSS) when provided in the community as home and community-based services (HCBS) can be a lifeline to help a person live safely at home and age with dignity. In a position paper on HCBS, A Blueprint for Reforming Medicaid Long-Term Services and Supports and Creating Good Caregiving Jobs, ATI Advisory CEO, and Nexus Fellow, Anne Tumlinson offered three recommendations for legislators and regulators to expand access to home-based care services sustainably and equitably.

1 – Providing states with better financial support, assurances and predictability

Medicaid accounts for 29% of total state spending across all funding sources, and LTSS is a substantial portion of this spend. This creates financial pressures, resulting in cuts to the Medicaid program during times of budget pressure, and reluctance to provide or expand services that are optional, such as HCBS LTSS.

IMMEDIATE RECOMMENDATIONS: Several policy and financing approaches (e.g., enhanced federal match for HCBS, state education on HCBS financial controls) increase access to HCBS by increasing funding and alleviating immediate state financial concerns.

LONGER-TERM RECOMMENDATIONS: Financing reform could include federalizing some portion of LTSS or creating a shared risk model between states and the federal government.

Read the full recommendation

2 – Modernizing long-standing Medicaid eligibility policies

Long-standing Medicaid eligibility policy creates a bias toward institutional care, making it difficult for individuals to remain in their home or the community when they have LTSS needs.

IMMEDIATE RECOMMENDATIONS: Several eligibility regulatory changes would increase access to HCBS and help ensure individuals have access to LTSS in the most appropriate setting of care.

LONGER-TERM RECOMMENDATIONS: National minimum eligibility standards applied across states would reduce inequity and improve access.

Read the full recommendation

3 – Investing in the direct care workforce delivering HCBS

Immediate and longer-term recommendations for increasing access to home and community-based services (HCBS), reducing institutional bias in Medicaid long-term services and supports (LTSS), and creating good caregiving jobs:

ISSUE: Direct care worker pay is relatively low and the work is demanding. Policymakers should take a comprehensive approach to fairly compensate; elevate; and retain, engage, and develop workers.

SHORT-TERM RECOMMENDATIONS: Increase the minimum wage, create a high-level HCBS and Direct Care Workforce coordinating office, make targeted investments in training, and launch a public service campaign to help address key workforce issues.

LONGER-TERM RECOMMENDATIONS: Improve jobs by enacting policies to support affordable childcare, healthcare, and paid sick leave; modernize training; and create a permanent federal Center for Direct Care Excellence.

Read the full recommendation

 

See the full Position paper

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meaningful reform in nursing homes

Seize the moment: Bob Kramer lays out path for meaningful reform in nursing homes in new Health Affairs blog

“The American long-term care system, particularly in skilled nursing facilities, has been exposed as deeply flawed, chronically underfunded, and in need of reform.” This bold statement is from Robert Kramer, Founder and Fellow of Nexus Insights, and Co-Founder and Strategic Advisor for NIC. It’s the opening line of his recent blog in Health Affairs.

Kramer delves deeply into the urgent problems facing nursing homes that have been spotlighted on the national stage by the pandemic and its tragic death toll among nursing home residents and staff. Kramer predicts the likely responses we can expect to see from nursing home operators, federal and state regulators and policy makers, and seniors and their families. But he urges, instead, a more thoughtful, complex and multi-faceted approach to solving the challenges of long-term care in nursing homes that involves dispensing with out-of-date assumptions, acknowledging the problems, and aligning the different stakeholders involved.

The problems he sees stem from undervaluing and undercompensating the work of caregivers, and the too-narrow focus of regulatory metrics on physical care needs, rather than the personal goals and aspirations of the residents themselves, and their quality of life. Other challenging problems include the long-term shortage of caregivers for a rapidly growing population of seniors, the lack of financial transparency, inadequate reimbursement models that incentivize the wrong behaviors, the age of nursing home infrastructure, and the financial impact of the COVID-19-related lawsuits that are certain to hit the beleaguered industry as the pandemic winds down.

“Every stakeholder must understand that this is a disruptive moment.” – Bob Kramer

The solutions Kramer proposes will require thoughtful cooperation and coordination among all the players in the industry, including industry providers, organized labor, consumer advocates, investors, and regulators. And it won’t be easy. But as Kramer points out, “Every stakeholder must understand that this is a disruptive moment. SNFs and long-term care are, for a moment, center stage. Those of us who care about this sector, and the millions of Americans it serves, must seize this moment.”

Link to full blog

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