Alice Bonner, PhD, RN, FAAN, Senior Advisor for Aging, Institute for Healthcare Improvement
This editorial is the work of four authors: two registered nurses with PhDs, one of whom is a former government/public health division director and one of whom leads a national foundation; a certified nursing assistant and director of a national CNA organization; and a nationally recognized health economist and nursing home expert. Their names and affiliations appear at the end of the article.
How We Got Here
For years, extended families formed the backbone of American communities. Children and young adults grew up living with parents and grandparents, or with the grandparents of friends and neighbors down the street. So why is it that we struggle with long-term care — how to create meaningful, purposeful living environments as we age? And why is it that skilled nursing and rehabilitation facilities and skilled nursing facilities (SNFs, historically called nursing homes) are always an afterthought, or completely invisible?
The greatest success story of the 20th century is human longevity; all of us love to tell the story of a relative or friend who has made it into their ninth or tenth decade. However, as a society we have not come to grips with how to care for older people. Antibiotics, pacemakers, renal dialysis, and artificial hearts are just a part of the story that has led to longevity — not to mention the extraordinary achievements of the public health system.
Why We Do This Work
Many of us have had a career focused on supporting or caring for older adults over decades. Why do we do this work? Because we believe we can create a comprehensive system of care, a continuum of health, housing, and social services that can better support ourselves — older people and our care partners — in social engagement and the life of communities. Due to a variety of factors, some form of nursing home care will always be a part of that continuum.
Many not-for-profit associations, for-profit companies, and government agencies focus on creating environments for optimal aging. The John A. Hartford Foundation, a foundation devoted to improving care for older adults, is dedicated to improving care of older adults in every place they reside. Every day the team focuses on its mission and work with national and international organizations, government agencies, universities, and all components of the healthcare system, to try to create Age Friendly Health Systems. They are sorely lacking.
Brief History and Evolution of Nursing Home Care
In the 1970s, the culture among nursing home staff and leadership was generally one of “let’s keep residents safe and dry.” This included a focus on preventing wandering and resident-to-resident altercations, ensuring that residents were fed, bathed, and dressed, and that their personal needs, such as elimination, were addressed.
There was little attention paid to cognitive, behavioral, or mental health issues or meaningful activities, due to a widespread belief that aging carried with it an irreversible downward trend in cognitive health, and that with few exceptions, there were no interventions to prevent or effectively treat or manage this “condition.” In addition, many nursing home workers and primary care/geriatric clinicians seemed to accept that using physical restraints, chemical restraints and similar measures were “appropriate” ways to manage older adults in this setting. As a result, rates of falls with injuries, serious skin breakdown, contractures, and other sequelae of those practices were considered a “normal” part of nursing home life. These issues were also common in rest homes and old age homes with little oversight or regulation.
Today, regulations are extensive, and the sanctions, when enforced, can be severe, ranging from fines to probation to closure. In particular, the Omnibus Reconciliation Act of 1987 (OBRA ’87) has shaped oversight for the past 30 years. The OBRA ‘87 standards overhauled nursing home regulation and sought to hold nursing homes to a higher standard. Quality has generally improved since the 1970s, but many nursing homes still struggle with providing high-quality care.
Precarious Financial Footing
Due to years of chronic underfunding by Medicaid, nursing homes have had a limited ability to meet the needs of residents. Furthermore, in recent years, private equity, venture capital firms, and other private investors have purchased independent nursing homes, often creating real estate investment trusts (REITs) or other financial structures that have taken money out of the system and focused on investor profits instead of quality measures and resident outcomes.
The current nursing home payment structure does not support a comprehensive system or continuum of care. Both post-acute (short-term) and long-term care are built on a highly flawed financial model in which SNF/NFs are expected to provide care with inadequate staffing or other resources, limited training, a lack of leadership, and a culture that does not promote, support, or encourage professional development and career advancement, particularly for certified nursing assistants (CNAs).
Advocacy for direct care workers has weakened over time, and their voices are often not heard in national or state policy discussions. CNAs are not part of decision-making, despite spending more hours with residents than any other nursing home healthcare worker and despite years of trying to bring attention to the abject poverty and challenges of raising a family on pitifully low wages, unpredictable hours, and limited benefits.
Federal and State Oversight of Care Delivery
Nursing homes are overseen primarily by state survey agencies, under a contract referred to as the 1864 Agreement, referencing chapter 1864 of the Social Security Act. Using the Code of Federal Regulations and additional state-specific regulations, surveyors inspect nursing homes on an annual basis and in response to complaints. The survey identifies areas of non-compliance; depending on the scope and severity, surveyors may impose fines, limited admissions, or other sanctions. Surveyors may only identify issues based on non-compliance with the regulations; they may not act as consultants and may not provide quality improvement guidance.
With limited funding, many nursing homes go without outside training or consulting, even when that need is reflected in the survey report or quality measures. As a result, articles in the press, social media, and other communications often place blame on nursing home owners, operators, or direct care staff when survey scores are low. This leads to teams feeling demoralized, discouraged and helpless; despite their best efforts in many cases, they are still portrayed as failing to provide what older adults and taxpayers expect and deserve. As a nation, we still struggle with how to accurately and consistently differentiate high versus low performing nursing homes.
Again, Workforce Crisis
Even as more older adults who require assistance with activities of daily living and chronic health issues choose to live at home, some individuals will always need SNF/NFs. Many of those individuals choose congregate living because they lack family or adequate social supports or have intensive medical needs that cannot be adequately met in the community. Furthermore, they may not be able to financially cover the costs of community care, and therefore spend down until they are eligible for Medicaid to cover nursing home costs. This creates issues of inequity, as those living in poverty or low-income areas are more likely to receive care in lower quality nursing homes. There are exceptions, but income-related aspects of nursing home care have been well described in the literature.
The most fundamental issue is a lack of workforce support and lack of a career ladder or lattice for CNAs and other nursing home workers. For decades, scientific papers and research studies have documented a need for the transformation of both financial and care delivery structures to properly care for nursing home residents, family members or care partners, communities, and nursing home staff.
In addition to workers receiving pay that is below a living wage (the average CNA hourly wage is $12 to$17 per hour nationally, according to the Bureau of Labor Statistics) and limited benefits, CNAs often have their hours cut without notice, leading many to work two or three jobs at a time in different nursing homes or home health agencies. Coupled with a lack of adequate supervision, many CNAs report that their work life feels lonely and isolating, and that making ends meet and supporting their families, often as single parents, has become nearly impossible. Intent to leave one’s job is high in this workforce; this must be addressed immediately.
What We Can Do Now
We must change the nature and compensation of direct care jobs in long-term care by incentivizing high school students, community college students, older adult workers, and others to want to work in this setting. And once in these jobs, we need to retain these new workers. Furthermore, we must create adequate supervision for CNAs, nurses, administrators, and other nursing home healthcare workers. Creating a positive and supportive culture with opportunities for career advancement is critical to enhancing care for all residents and promoting productive, sustainable careers in these settings.
There are multiple, potential opportunities and approaches to address these issues. We propose one option here for readers’ consideration.
We propose a state-based initiative to test financial and care delivery restructuring over the next three years.
- We will develop and enhance critical relationships in one state with a small number of nursing homes.
- Relationships will include those within Health and Human Services (HHS), the State Survey Agency, Medicaid Agency, Labor and Development, Unit on Aging, advocacy groups, professional associations, and others.
- We propose that the governor and state HHS secretary amend state regulations to require any nursing home operating in that state to pay a living wage to CNAs (e.g., $30,000 per year plus benefits, such as transportation and child care), and guarantee consistent hours for at least one year, with 60 days notification if the number of hours per week is to be adjusted up or down.
- We will analyze clinical and resident outcomes, as well as staff turnover, job satisfaction and intent to leave, and other key measures of nursing home quality and career development.
This will not be an easy or quick fix. It has taken decades to get to this point, and centuries of an ageist culture that values older adults but has not invested in processes for taking care of them. Historically, some nursing home owners and operators have pushed back, fearing potential financial loses if CNAs’ salaries and hours are increased. In addition, Medicaid and HHS agencies will have to find funding to cover potential daily rate increases at a time when most governors are focused on covering losses due to COVID-19 and expanding home and community-based services, which most older adults say that they prefer.
Creating a continuum of care in which as many older adults as possible live at home, and only those who prefer or require more intensive care are admitted to nursing homes will be a challenge for state leaders. That is why testing this in one state with a small number of nursing homes is a reasonable next step. An evaluation must be part of the initiative from the beginning, designed by point-of-care clinicians and a health economist and health services research team. One funding option to consider would be that state or federal civil money penalties (CMP) could be dedicated to the initiative and evaluation.
Reports by the U.S. Government Accountability Office (GAO) and Office of the Inspector General for the United States Department of Health and Human Services (OIG) have revealed a high number of nursing homes that have inadequate emergency preparedness and management plans, which CMS requires. Also, the COVID-19 pandemic has revealed weaknesses in infection prevention and control policies nationally. Much more work needs to be done to prepare nursing home teams for the next pandemic or other threats to life and safety.
What We Have Learned from COVID-19 and How to Move Forward Now
The COVID experience has shown us that nursing homes lack infrastructure, were poorly prepared, and poorly staffed, and that preventative care was almost non-existent in many communities. We can change that, and we’re optimistic that the COVID-19 crisis will help us reframe care of older adults in a way in which we anticipate and prepare for the next crisis. There will be a next Sandy, a next Katrina, a next set of fires or other disasters with devastating consequences. Surely, we can determine the best way to anticipate these events. With the advent of telehealth, which is becoming the new normal, innovative staffing models, as well as all smart home techniques that are rapidly emerging, there is literally no reason to be in this position again unless we choose to ignore what’s happening around us.
Without such an approach, care in many U.S. nursing homes will continue to be substandard, and not what we want for ourselves. Given the incredible dedication and hard work of so many point-of-care providers in nearly 15,000 nursing homes, we must do better than just writing about the situation. And we must start today.
If you would like to join the movement to take action to resolve the nursing home workforce crisis, please contact us at alicebonner.rn@gmail.com.
This blog post was co-authored by Alice Bonner, PhD, RN, FAAN (Senior Advisor for Aging, Institute for Healthcare Improvement), Terry Fulmer, PhD, RN, FAAN (President, John A. Hartford Foundation), Lori Porter (Chief Executive Officer, National Association of Health Care Assistants), and David Grabowski, PhD (Professor of Health Care Policy, Department of Health Care Policy, Harvard Medical School).