WASHINGTON — Providing high-quality care for all nursing home residents requires collaboration among federal and state governments, health care providers, payers, and others to completely transform the way nursing home care is delivered, financed, and regulated, says a new report from the National Academies of Sciences, Engineering, and Medicine. Strengthening the nursing home workforce, improving emergency preparedness, and increasing the transparency and accountability of nursing homes’ finances, operations, and ownership are key actions among the report’s comprehensive recommendations.

“The way in which the United States finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, fragmented, and unsustainable,” said Betty Ferrell, director of nursing research and education and professor at City of Hope Medical Center, and chair of the committee that wrote the report. “We must stop viewing nursing home residents as ‘them’ — they are our grandparents, parents, friends, siblings, and veterans. The recommendations in this report could profoundly change the delivery of care, and we’re confident they align with what we would want for ourselves and our loved ones if we or they were in a nursing home.”

The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff starts with a foundational goal — providing person-centered care that honors residents’ values and preferences. The report calls for the development of quality measures for areas such as palliative care and psychosocial and behavioral health, the development of an overall health equity strategy for nursing homes, and the collection and reporting of information about resident and family satisfaction via Care Compare, the Centers for Medicare & Medicaid Services (CMS) website that reports on nursing home quality.

For many decades, the nursing home sector has experienced underinvestment in ensuring the quality of care and a lack of accountability for resource allocation. The report’s recommendations likely will require a significant investment of additional financial resources at the federal and state levels and from nursing homes. However, the committee noted that key partners, such as CMS, may not currently have the full authority or resources to carry out the actions recommended, and therefore, congressional action may be required.

Preparing for Emergencies
As of February 2022, more than 149,000 nursing home residents and more than 2,200 nursing home staff members had died of COVID-19. Even before the pandemic, many facilities did not have adequate expertise and experience in infection prevention and control practices. Moving forward, nursing homes should be included in emergency planning, preparedness, and response at the federal, state, and local levels, the report says. This will help ensure nursing homes have access to vital resources, such as personal protective equipment, and that they receive ongoing assistance, education, and training on infection prevention and control as well as general preparedness for future natural disasters or public health emergencies.

Improving Resident Care
Achieving person-centered care that reflects resident values and preferences starts with the resident care planning process. Nursing homes, with CMS oversight, should identify and accurately document the care preferences of residents and their families. Staff should ensure the care plan addresses medical, psychosocial, and behavioral health needs, and should revisit this plan at least quarterly. Federal agencies, academic institutions, and private foundations should fund research on the care models and specific factors (such as the physical environment and staffing ratios) that best meet the needs of specific populations. In addition, the report recommends identifying pathways to provide financial incentives to nursing homes for the adoption of certified electronic health records, which can improve the coordination of care.

The nation’s nursing home infrastructure is aging, the report adds, and facility size and room sharing could be major predictors of infection rates. Nursing home owners, with the support of CMS and other federal agencies, should construct and renovate facilities to provide smaller, more home-like environments, which may include single-occupancy bedrooms and private bathrooms. These changes can help prevent the spread of infection while enhancing the quality of life for residents.

Building a High-Quality Workforce
To build a nursing home workforce that is well prepared, empowered, and appropriately compensated, the report recommends increasing the numbers and the qualifications of all types of nursing home workers. CMS should establish minimum education and national competency standards for a variety of workers. While this may be challenging amid COVID-19-related staffing shortages, enhancing requirements will improve the quality of care, further professionalize the workforce, and in turn, contribute to the desirability of working in a nursing home. CMS should immediately implement requirements for 24/7 registered nurse staffing and a full-time social worker in all nursing homes. To inform future staffing requirements, the U.S. Department of Health and Human Services (HHS) should fund research on the minimum and optimum staffing levels for nurses, therapists, recreational staff, social workers, and other employees.

Nursing homes should provide ongoing training in diversity and inclusion for all workers and leadership, and provide family caregivers with resources and training as needed or desired. To recruit and retain all types of staff, nursing homes should ensure competitive wages and benefits, including health insurance, child care, and sick pay.

Strengthening Financing and Payment
The current approach to financing nursing home care is highly fragmented. The federal-state Medicaid program is the dominant payer of long-stay nursing home care, while the federal Medicare program only covers short-stay post-acute care. Services such as hospice care are paid separately and are not well integrated into standard nursing home care. Private insurance coverage for long-term care is limited, and relatively few people can afford to pay out of pocket for an extended nursing home stay. The report calls on HHS to study the design of a new long-term care benefit. The report also provides recommendations to improve the value of care by linking payments more closely to quality using alternative payment model demonstration projects for long-stay care and bundled payment arrangements for short-stay post-acute care.

Increasing Transparency and Accountability
The report recommends collecting, auditing, and making publicly available detailed facility-level data on the finances, operations, and ownership of all nursing homes. This will inform evaluations of how Medicare and Medicaid payments are spent, and the impact of ownership models and spending patterns on the quality of care.

The report also calls for CMS and states to improve oversight of nursing homes, to avoid a repeat of the failures that occurred during the COVID-19 pandemic. It recommends that federal and oversight agencies impose enforcement actions such as denial of new or renewed licensure on owners with a pattern of poor-quality care across facilities. As part of its efforts to strengthen oversight of nursing homes, CMS should also ensure state survey agencies have the capacity, organizational structure, and resources for their responsibilities, including monitoring of nursing homes, investigation of complaints, and enforcement of regulations.

Changing Societal Views on Aging
The COVID-19 pandemic highlighted nursing home residents’ vulnerability and the pervasive ageism evident in undervaluing the lives of older adults, the report says. High-quality care cannot be delivered without a major overhaul of worker training and support, the culture within nursing homes, and how society views aging in general. Nursing home leaders should drive these changes.

“Aging should not be something to be dreaded, but something to be revered, and as such, nursing homes should provide the highest quality and compassionate care to enhance the lives of those in their care. This report delivers a blueprint to build a system of nursing homes that truly centers the lives of older adults and gives them respect, dignity, and protection,” said Victor J. Dzau, president of the National Academy of Medicine. “The COVID-19 pandemic highlighted the persistent inequities and inadequacies in American nursing home care, clearly illustrating that this system is broken. Addressing these vulnerabilities must include building a high-quality workforce, ensuring a more rational payment system, and directly addressing ageism so we can provide care that improves, not only sustains, the lives of our aging loved ones.”

While all of the report’s recommendations target areas that require immediate attention, the committee recognized that some recommendations can be fully implemented immediately while others will require planning, coordination, and larger scale effort. The committee categorized each of the components of their recommendations into an estimated implementation timeline.

The study — undertaken by the Committee on the Quality of Care in Nursing Homes — was sponsored by the John A. Hartford Foundation, the Commonwealth Fund, Sephardic Foundation on Aging, Jewish Healthcare Foundation, and the Fan Fox & Leslie R. Samuels Foundation. The National Academies of Sciences, Engineering, and Medicine are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine. They operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln.

Contact:
Dana Korsen, Director of Media Relations
Office of News and Public Information
202-334-2138; e-mail news@nas.edu

Featured Report

2022

Nursing homes play a unique dual role in the long-term care continuum, serving as a place where people receive needed health care and a place they call home. Ineffective responses to the complex challenges of nursing home care have resulted in a system that often fails to ensure the well-being and safety of nursing home residents. The devastating impact of the COVID-19 pandemic on nursing home residents and staff has renewed attention to the long-standing weaknesses that impede the provision of high-quality nursing home care.

With support from a coalition of sponsors, the National Academies of Sciences, Engineering, and Medicine formed the Committee on the Quality of Care in Nursing Homes to examine how the United States delivers, finances, regulates, and measures the quality of nursing home care. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff identifies seven broad goals and supporting recommendations which provide the overarching framework for a comprehensive approach to improving the quality of care in nursing homes.

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• Press Release
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• Policy Brief: Financing
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