Nursing Home Reform

Swinging for the Fences: 7 Recommendations for Nursing Home Reform

“Our whole policy infrastructure for nursing homes is broken in many respects: how we pay for them, how we regulate them and how they deliver services,” said Dr. David Grabowski, Professor of Health Care Policy at Harvard Medical School and a Fellow for Nexus Insights.

Dr. Grabowski was selected to participate in a National Academies of Sciences, Engineering, and Medicine commission tasked in reforming nursing home care. The 19-member committee worked for 18 months to create a report (published April 2022) with seven actionable recommendations to improve every aspect of nursing home care in the United States.

“The recommendations are bold. Nobody has accused us of trying to hit a single. We tried to swing for the fences in each of the areas of the report,” said Grabowski on a recent “Elevate Elder Care” podcast hosted by Susan Ryan of The Green House Project. “They can’t just be nibbling around the edges. They have to be transformative.”

The commission identifies seven key aspects in need of reform:

  1. Deliver comprehensive, person-centered, equitable care: “The system is broken because it’s not about the people receiving the services or the people providing the care,” said Grabowski.
  2. Prepare, empower and better compensate staff: “Everybody knows we have too few staff, training is not always up to par, we don’t pay them a competitive wage and benefits. This goal is around minimum staffing, ensuring that working conditions for staff are better, and improving the way staff are valued, paid and empowered.”
  3. Increase transparency & financial accountability: “This is an issue that predates the pandemic. Ownership is so much more complex, and it’s more necessary than ever that we get accountability and transparency, to make sure money is being spent on what it should be.”
  4. Create a more rational and robust financing system: “We propose a federal long-term care benefit. In other areas we have comprehensive federal benefits, but we piece it together for long-term care,” Grabowski said. “We should be paying a rate commensurate with a high level of quality. We have to figure out how to pay for it.”
  5. Reimagine quality assurance and regulation: “There is very little consistency among states. More data is needed about which quality assurance activities work, how we make sure the regulation is serving the residents well, and how we ensure that we’re improving performance.”
  6. Expand and enhance quality measurement and improvement: “A lot of our quality measures don’t work well. We have to reimagine quality measures, to make sure they reflect what residents and their families want in a long-term care experience.”
  7. Adopt health information technology: “Nursing homes lag behind other parts of the healthcare system, and they aren’t well connected to other parts of the system. It’s so important for care coordination. But they haven’t had the dollars or the incentives to do it.”

Grabowski is hopeful that the time is right for meaningful reform.

“The problems and the solutions have been around for 35 years, but COVID shone a light on it. It’s amazing the attention nursing homes have received. There’s tremendous interest now. Americans are waking up and saying, ‘Hey, this system isn’t working.’ There are long-standing issues that have gone unaddressed for decades. COVID galvanized Americans to look at this issue differently than they had previously.”

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