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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

THE NATIONAL IMPERATIVE TO IMPROVE NURSING HOME QUALITY Honoring Our Commitment to Residents, Families, and Staff Committee on the Quality of Care in Nursing Homes Board on Health Care Services Health and Medicine Division A Consensus Study Report of PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 This activity was supported by The John A. Hartford Foundation, The Common- wealth Fund, The Sephardic Foundation on Aging, Jewish Healthcare Foundation, and The Fan Fox & Leslie R. Samuels Foundation. Any opinions, findings, conclu- sions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/26526 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2022 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2022. The national imperative to improve nursing home quality: Honoring our commitment to residents, families, and staff. Washington, DC: The National Academies Press. https://doi.org/10.17226/26526. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

COMMITTEE ON THE QUALITY OF CARE IN NURSING HOMES BETTY R. FERRELL (Chair), Director and Professor, City of Hope National Medical Center, Division of Nursing Research and Education GREGORY L. ALEXANDER, Professor of Nursing, Columbia University School of Nursing MARY ERSEK, Senior Scientist, Department of Veteran Affairs; Professor of Palliative Care, University of Pennsylvania Schools of Nursing and Medicine COLLEEN GALAMBOS, Helen Bader Endowed Chair in Applied Gerontology and Professor, University of Wisconsin–Milwaukee; Adjunct Professor, Medical College of Wisconsin DAVID C. GRABOWSKI, Professor of Health Care Policy, Harvard Medical School KATHY GREENLEE, Chief Executive Officer, Greenlee Global LLC LISA G. KAPLOWITZ, Physician Consultant, COVID Vaccine Unit, Virginia Department of Health R. TAMARA KONETZKA, Louis Block Professor of Public Health Sciences, University of Chicago CHRISTINE A. MUELLER, Professor and Senior Executive Associate Dean for Academic Programs, University of Minnesota School of Nursing MARILYN J. RANTZ, Curators’ Professor Emerita, University of Missouri Sinclair School of Nursing DEBRA SALIBA, Director, Borun Center and Professor of Medicine, University of California, Los Angeles; Physician Scientist, Geriatrics Research Education and Clinical Center, Los Angeles Veterans Health Administration; Senior Natural Scientist, RAND WILLIAM SCANLON, Consultant, West Health PHILIP D. SLOANE, Goodwin Distinguished Professor of Family Medicine and Geriatrics, School of Medicine and Co-Director, Program on Aging, Disability and Long Term Care, Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill DAVID G. STEVENSON, Professor, Department of Health Policy, Vanderbilt University School of Medicine JASMINE L. TRAVERS, Assistant Professor, Rory Meyers College of Nursing, New York University REGINALD TUCKER-SEELEY, Vice President, Health Equity, ZERO-The End of Prostate Cancer; Edward L. Schneider Assistant Professor of Gerontology, Leonard Davis School of Gerontology, University of Southern California RACHEL M. WERNER, Executive Director, Leonard Davis Institute of Health Economics; Professor of Medicine, University of Pennsylvania; Core Investigator, Crescenz Veterans Affairs Medical Center PREPUBLICATION COPY—Uncorrected Proofs

Study Staff LAURENE GRAIG, Study Director TRACY A. LUSTIG, Study Director KAITLYN FRIEDMAN, Associate Program Officer (through December 2021) NIKITA VARMAN, Research Associate RUKSHANA GUPTA, Research Assistant MICAH WINOGRAD, Financial Officer ANNE MARIE HOUPPERT, Senior Librarian SHARYL J. NASS, Director, Board on Health Care Services Consultants JOE ALPER, Science Writer MARISA G. PINEAU, FrameWorks Institute PREPUBLICATION COPY—Uncorrected Proofs

Reviewers This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manu- script remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: JULIA ADLER-MILSTEIN, University of California, San Francisco RICHARD D. ALBA, The City University of New York ALICE BONNER, Institute for Healthcare Improvement BARBARA BOWERS, University of Wisconsin KATHY BRADLEY, Our Mother’s Voice STUART M. BUTLER, The Brookings Institution TOBY S. EDELMAN, Center for Medicare Advocacy CHARLENE A. HARRINGTON, University of California, San Francisco BECKY A. KURTZ, Atlanta Regional Commission NANCY KUSMAUL, University of Maryland Baltimore County ROBERTA P. LAVIN, University of New Mexico CARI LEVY, University of Colorado vii PREPUBLICATION COPY—Uncorrected Proofs

viii REVIEWERS VINCENT MOR, Brown University TRICIA NEUMAN, Kaiser Family Foundation JOSEPH G. OUSLANDER, Florida Atlantic University KATHLEEN T. UNROE, Indiana University Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by CHRISTINE K. CASSEL, University of California, San Francisco, and DAVID B. REUBEN, Univer- sity of California, Los Angeles. They responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. PREPUBLICATION COPY—Uncorrected Proofs

Acknowledgments The study committee and the Health and Medicine Division (HMD) project staff take this opportunity to recognize and thank the many indi- viduals who shared their time and expertise to support the committee’s work and to inform deliberations. This committee appreciates the sponsors of this study for their generous financial support: The John A. Hartford Foundation, The Commonwealth Fund, Jewish Healthcare Foundation, The Sephardic Foundation on Aging, and The Fan Fox & Leslie R. Samuels Foundation. The contents provided do not necessarily represent the official views of the sponsors. The committee benefitted greatly from discussions with individuals who made presentations during the committee’s open sessions and participated in the discussions: Donald M. Berwick, Institute for Healthcare Improvement Tom Betlach, Speire Healthcare Strategies Alice Bonner, Institute for Healthcare Improvement Wendy Boren, Quality Improvement Program for Missouri Kathy Bradley, Our Mother’s Voice Scott Brunner, Kansas Department for Aging and Disability Services Margaret P. Calkins, IDEAS Institute Eric Carlson, Justice in Aging Mitzi Daffron, Qsource, Medicare Quality Innovation Network - Quality Improvement Organization for Indiana John Dicken, U.S. Government Accountability Office Ruth Ann Dorrill, Office of the Inspector General ix PREPUBLICATION COPY—Uncorrected Proofs

x ACKNOWLEDGMENTS Toby S. Edelman, Center for Medicare Advocacy Barbara Coulter Edwards, BCE Health Policy Barbara Frank, B&F Consulting, Inc. John Hagg, Office of the Inspector General Lacey Hunter, Kansas Department for Aging and Disability Services Ruth Katz, Leading Age Robert G. Kramer, National Investment Center for Seniors Housing and Care, Nexus Insights Beverly L. Laubert, Ohio Department of Aging Shari M. Ling, Centers for Medicare & Medicaid Services Nicky Martin, Quality Improvement Program for Missouri Richard J. Mollot, The Long-Term Care Community Coalition Anne Montgomery, Altarum David A. Nace, AMDA – The Society for Post-Acute and Long-Term Care Medicine, and University of Pittsburgh Arif Nazir, Signature HealthCARE Joseph G. Ouslander, Florida Atlantic University Mary K. Ousley, American Health Care Association Kezia Scales, PHI Karen Schoeneman, Karen Schoeneman Consulting Lori O. Smetanka, The National Consumer Voice for Quality Long-Term Care Karl Steinberg, AMDA – The Society for Post-Acute and Long-Term Care Medicine, and Mariner Health Central Amy Stewart, American Association of Post-Acute Care Nursing Karin J. Wallestad, U.S. Government Accountability Office Michael Wasserman, California Association of Long-Term Care Medicine Polly Weaver, Healthcare Management Solutions, LLC Faith Wiggins, 1199SEIU Funds The committee is very grateful to these presenters for volunteering to share their knowledge, data, and expert opinions with the committee and the members of the public who attended the committee’s open sessions. The committee also appreciates the many nursing home residents, families, and staff who submitted their perspectives and experiences. Deep appreciation goes to staff at the National Academies of Sciences, Engineering, and Medicine for their efforts and support in the report pro- cess, especially to Lauren Shern, Leslie Sim, Tina Seliber, Devona Overton, Stephanie Miceli, Dorothy Zolandz, and the staff of the National Acad- emies Research Center, including Rebecca Morgan. The committee also gives special thanks to Joe Alper for his writing and editing contributions, PREPUBLICATION COPY—Uncorrected Proofs

ACKNOWLEDGMENTS xi Marissa Pineau for her messaging and framing expertise, and Annalee Gonzales for her graphic design support. Finally, the committee also recognizes and extends gratitude for all the nursing home residents, families, staff, and organizations that have fought tirelessly to improve nursing home care. PREPUBLICATION COPY—Uncorrected Proofs

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Contents PREFACExvii ACRONYMSxxi ABSTRACTxxv SUMMARY1 1 INTRODUCTION 25 Study Context, 26 Study Origin and Statement of Task, 29 Previous Work of the National Academies, 29 Study Approach and Scope, 31 Conceptual Model of Nursing Home Quality, 37 Organization of the Report, 41 Conclusion, 42 References, 42 2 EVOLUTION AND LANDSCAPE OF NURSING HOME CARE IN THE UNITED STATES 47 Brief History of Nursing Homes, 47 Current Nursing Home Population, 49 Nursing Home Characteristics, 58 Factors that Influence the Quality of Care in Nursing Homes, 62 Critical Impact of COVID-19 on Nursing Homes, 66 xiii PREPUBLICATION COPY—Uncorrected Proofs

xiv CONTENTS Strengthening Connections of Nursing Homes to the Community and Broader Health Care System, 72 The Future of Nursing Home Care, 74 References, 76 3 QUALITY MEASUREMENT AND QUALITY IMPROVEMENT 89 The Purpose of Quality Measurement, 89 Principles and Definitions, 91 Evolution of Quality Measurement in Nursing Homes, 92 Care Compare and the CMS Five-Star Rating System, 94 Resident- and Family-Reported Outcomes: Quality of Life, Experience of Care, and Satisfaction, 105 Overview of Quality Improvement, 111 Federal Initiatives for Quality Improvement, 113 State and Local Initiatives for Quality Improvement, 117 Other Approaches to Quality Improvement, 122 Technical Assistance for Quality Improvement, 123 Quality Improvement and Disparities, 125 Coordinated Efforts During the COVID-19 Pandemic, 126 The Future of Quality Improvement in Nursing Homes, 127 Key Findings and Conclusions, 128 References, 130 4 CARE DELIVERY 145 Needs-Based Care for Nursing Home Residents, 146 Assessing the Needs of Nursing Home Residents, 148 Providing Care to Address Residents’ Needs, 158 Models of Care Delivery, 197 Key Findings and Conclusions, 198 References, 199 5 THE NURSING HOME WORKFORCE 221 The Overall Nursing Home Workforce, 222 Nursing Home Administration and Leadership, 226 Primary Care Providers, 234 Licensed Nurses, 237 Nurse Staffing, Regulation, and Quality of Care, 240 Infection Prevention and Control Leadership, 245 Psychosocial and Spiritual Care Providers, 247 Other Clinical Staff, 252 Direct-Care Workers, 256 Family Caregivers, 265 PREPUBLICATION COPY—Uncorrected Proofs

CONTENTS xv Volunteers, 268 Equity and the Workforce, 269 Factors That Influence the Relationship Between Staffing and Quality, 271 COVID-19 and Nursing Home Staffing, 273 Key Findings and Conclusions, 278 References, 281 6 NURSING HOME ENVIRONMENT AND RESIDENT SAFETY 303 Ensuring the Safety of Nursing Home Residents, 303 Nursing Home Emergency Planning, Preparedness, and Response, 324 The Physical Environment, 329 Key Findings and Conclusions, 341 References, 342 7 PAYMENT AND FINANCING 357 Paying for Nursing Home Care, 357 Variability between Medicare and Medicaid Payments, 364 Value-Based Payment Models and the Impact on Quality of Care, 366 Financing Nursing Home Care, 380 Key Findings and Conclusions, 385 References, 388 8 QUALITY ASSURANCE: OVERSIGHT AND REGULATION399 History of Quality Assurance in Nursing Homes, 399 Omnibus Budget Reconciliation Act of 1987, 401 Federal and State Regulation, 403 Private Accreditation, 415 Enforcement and Penalties, 415 CMS Oversight and Performance of the State Survey and Certification Processes, 420 Long-Term Care Ombudsman Programs, 423 Resident and Family Councils, 427 Effectiveness of Quality Assurance For Improving the Quality of Care, 428 Transparency and Accountability, 429 Nursing Home Oversight During COVID-19, 434 Key Findings and Conclusions, 437 References, 440 PREPUBLICATION COPY—Uncorrected Proofs

xvi CONTENTS 9 HEALTH INFORMATION TECHNOLOGY 453 Evolution of Health Information Technology in Nursing Homes, 455 Role of HIT in Quality Care in Nursing Homes, 457 Challenges of HIT Adoption and Use in Nursing Homes, 468 HIT and the COVID-19 Pandemic, 473 Other HIT Considerations for Quality Improvement, 478 Key Findings and Conclusions, 481 References, 482 10 RECOMMENDATIONS 495 Committee Vision and Guiding Principles, 497 Overarching Goals and Recommendations, 499 Goal 1: Deliver Comprehensive, Person-Centered, Equitable Care that Ensures Residents’ Health, Quality of Life, and Safety; Promotes Autonomy; and Manages Risks, 501 Goal 2: Ensure a Well-Prepared, Empowered, and Appropriately Compensated Workforce, 508 Goal 3: Increase Transparency and Accountability of Finances, Operations, and Ownership, 518 Goal 4: Create a More Rational and Robust Financing System, 519 Goal 5: Design a More Effective and Responsive System of Quality Assurance, 525 Goal 6: Expand and Enhance Quality Measurement and Continuous Quality Improvement, 530 Goal 7: Adopt Health Information Technology in All Nursing Homes, 535 Conclusion, 541 APPENDIXES A Biographic Sketches 543 B Examples from the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents 555 C Recommendations by Area of Measurement and by Area of Research 561 D Recommendations by Responsible Partners 565 E Recommendations Timeline 573 PREPUBLICATION COPY—Uncorrected Proofs

Preface The Committee on the Quality of Care in Nursing Homes began their work in the fall of 2020 at a pivotal time when a bright light had been cast on care delivered in nursing homes because of the COVID-19 pandemic. While much of society previously had little awareness of the care delivered in nursing homes, the evening news channels and social media projected daily images of the pandemic’s impact and of the inadequate care that put the safety of both residents and staff at risk while distraught family mem- bers watched from afar as their frail older loved ones were kept in isola- tion. The committee worked to describe the care being delivered in nursing homes before the pandemic, now made manifest by the crisis. The committee was given a substantial task of examining how the United States “delivers, finances, measures, and regulates the quality of nursing home care.” The challenge was enormous, but as reflected in the final recommendations, real change in nursing home care will require bold action in each of these domains. In the report chapters that follow, the committee presents the evidence of the need for change followed by specific recommendations. The final chapter concludes that “the way the United States finances, delivers, and regulates care in nursing home settings is inef- fective, inefficient, fragmented, and unsustainable.” The discussions of the committee often centered around core values of a society that truly cares for the most vulnerable. We began our work with creating a word map of key words and phrases that described what we all hoped for in nursing home care. Words such as safety, equity, peaceful, joyous, integrity, and comfort were often shared as we all imagined what care in a nursing home should be. The committee members were constantly xvii PREPUBLICATION COPY—Uncorrected Proofs

xviii PREFACE aware of the data, literature, and daily news stories of the travesties in nursing home care as they wrote this report. The committee also recognized the many examples of outstanding care being provided in nursing homes and realized that across the United States nursing home staff representing all disciplines are each day providing wonderful care to residents who they consider as beloved family members. Sadly, these staff have put their own lives at risk and are often not well trained, supported, or compensated. This report and the committee’s recommendations assert strongly that residents of nursing homes need better care—and the people caring for them also need better care. The committee report is clear that we will not realize good-quality care of residents until we invest in the bedside staff who care for them. The committee often reflected on the 1986 Institute of Medicine report Improving the Quality of Care in Nursing Homes, which was a critical milestone yet whose recommendations were not fully realized. As a na- tion we have made promises for better care in nursing homes, and those promises have not been kept. Our hope is that commitment and promises for quality nursing home care that were voiced throughout the pandemic will become promises kept. The recommendations from the committee are thoughtful and strategic. Perhaps the committees’ biggest challenges came when we tried to balance the need for very aggressive, overdue change with the reality of limited resources, competing priorities, and the complexity of systems change. We believe the recommendations in this report achieve that balance of what is possible and what is desperately needed. Is it too much to ask that each and every resident in every nursing home receives care that includes high-quality physical care, behavioral health, safety, and psychological support? Is it too much to ask for a plan of care to establish what is most needed for each resident to receive high-quality care that is truly person-centered? Are we too bold to recommend on-site reg- istered nurse coverage in nursing homes, a social worker, and an infection control specialist? After all that we have witnessed during the COVID-19 pandemic, is it too much to ask that nursing assistants are better trained to deliver care to often frail people with limited social support or resources in the last years of their lives? It is not too much to ask that all residents re- ceive good-quality care regardless of race, ethnicity, or geographic location? In fact, the recommendations in this report are no more than what any one of us would want for ourselves or for those we love if we or they were in a nursing home. How can we not accept the committee’s recommendations and profoundly change the delivery of care in U.S. nursing homes? As with the evaluation of most areas of significant importance to our society, adopting and implementing the recommendations of this report will require more than funding, organizational commitment, education, and changing health policy—it will require moral courage. Improving the PREPUBLICATION COPY—Uncorrected Proofs

PREFACE xix quality of care in nursing homes for the decades ahead will be a continuing process requiring research to strengthen our knowledge of best care, test models to deliver that care, and investment in the education and training of all of those who work in nursing homes. The recommended approach is bold, but it is possible. But most importantly, it is right. Indeed, improving nursing home care is a moral imperative because it is clearly the right thing to do. It is also a national imperative because it represents society’s com- mitment to caring for those who cannot care for themselves. It has been a great privilege to have served as chair of this committee. This report will be published as I celebrate my 45th year as a nurse, and I consider it one of the highlights of my career to have devoted over a year to working with this committee of some of the most dedicated colleagues I have known. Most have devoted their careers to advocating for improved care in nursing homes—a pursuit that has not been well funded, often rec- ognized, or rewarded. These members each brought their knowledge and their passion for improved care to the table. We are in great debt to the staff of the National Academies for their commitment to this work. Laurie Graig and Tracy Lustig as senior program staff led the project with the greatest integrity and vision. The entire staff of the National Academies, including Kaitlyn Friedman, Nikita Varman, and Rukshana Gupta, offered their dedication, organization, and energy to a task that at times seemed overwhelming. As a nation, we will hopefully see the COVID-19 pandemic resolve in the months that will follow the release of this report. It will be too easy to turn our eyes away from the reform needed in nursing home care. This is the moment; this is the time to keep the promise of better care for those who are the most vulnerable in our society. The committee has delivered the blueprint to build a system of care that honors those who call the nursing home their home and the dedicated staff who care for them. Improving care in nursing homes is possible. It can be done. It must be done. Betty Ferrell, Ph.D., FAAN, FPCN, CHPN, Chair Committee on the Quality of Care in Nursing Homes PREPUBLICATION COPY—Uncorrected Proofs

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Acronyms and Abbreviations AADNS American Association of Directors of Nursing Services ABPLM American Board of Post-Acute and Long-Term Care Medicine ACA Patient Protection and Affordable Care Act ACL Administration for Community Living ACO accountable care organization ACP advance care planning ADE adverse drug event ADL activity of daily living ADRD Alzheimer’s Disease and related dementias AHCA American Health Care Association AHRQ Agency for Healthcare Research and Quality AMDA Society for Post-Acute and Long-Term Care Medicine AONL American Organization of Nursing Leaders APM alternative payment model APRN advance practice registered nurse APS adult protective services ATOP Nevada Admissions and Transitions Optimization Program BIPOC Black, Indigenous, and other people of color BPCI Bundled Payments for Care Improvement Initiative BSW bachelor’s degree in social work CAH critical access hospital CAHPS Consumer Assessment of Healthcare Providers and Systems program xxi PREPUBLICATION COPY—Uncorrected Proofs

xxii ACRONYMS AND ABBREVIATIONS CASPER  Certification and Survey Provider Enhanced Reporting system CDC Centers for Disease Control and Prevention CE continuing education CHIP Children’s Health Insurance Program CJR Comprehensive Care for Joint Replacement Model CLASS Act Community Living Assistance Services and Supports Act CMMI Center for Medicare & Medicaid Innovation CMS Centers for Medicare & Medicaid Services CNA certified nursing assistant COVID-19  severe acute respiratory syndrome coronavirus-19 (SARS-CoV-2) CRB care-resistant behavior C-SNP chronic condition special needs plan CSWE Council on Social Work Education DHS U.S. Department of Homeland Security DNR do not resuscitate order DOJ U.S. Department of Justice D-SNP dual special needs plan ECHO Extension for Community Healthcare Outcomes ED emergency department EHR electronic health record eMAR electronic medication management system EMR electronic medical record ESF emergency support function FEMA Federal Emergency Management Agency FFS fee-for-service FIDE fully integrated dual eligible SNP FY fiscal year GAO U.S. Government Accountability Office HAI health care–associated infection HHS U.S. Department of Health and Human Services HIE health information exchange HIT health information technology HITECH Health Information Technology for Economic and Clinical Health Act of 2009 HRSA Health Resources and Services Administration HUD U.S. Department of Housing and Urban Development PREPUBLICATION COPY—Uncorrected Proofs

ACRONYMS AND ABBREVIATIONS xxiii IHI Institute for Healthcare Improvement INTERACT Interventions to Reduce Acute Care Transfers program IOM Institute of Medicine I-SNP institutional special needs plan LGBTQ+ lesbian, gay, bisexual, transgender, queer (or questioning) LPN licensed practical nurse LTC long-term care LTSS long-term services and supports LVN licensed vocational nurse MA Medicare Advantage MCWB Mouth Care Without a Battle MDS Minimum Data Set MedPAC Medicare Payment Advisory Commission MIPS Merit-Based Incentive Payment System MOQI Missouri Quality Initiative MSW master’s degree in social work NAICS North American Industry Classification System NASW National Association of Social Workers NCAL National Center for Assisted Living NIH National Institutes of Health NNHI National Nursing Home Initiative NP nurse practitioner NQF National Quality Forum NRF National Response Framework NY–RAH New York-Reducing Avoidable Hospitalizations project OBRA 87 Omnibus Budget and Reconciliation Act of 1987 OIG U.S. Office of the Inspector General ONC Office of the National Coordinator for Health Information Technology OPTIMISTIC Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care program OTC over the counter P4P pay-for-performance PA physician assistant PASRR preadmission screening and annual resident reviews PDPM Patient Driven Payment Model PIPP Minnesota Performance-Based Incentive Payment Program PREPUBLICATION COPY—Uncorrected Proofs

xxiv ACRONYMS AND ABBREVIATIONS POLST physician’s order for life-sustaining treatment PPE personal protective equipment QAPI quality assurance and performance improvement programs QIO quality improvement organization QIPMO Quality Improvement Program of Missouri QOL quality of life RAI Resident Assessment Instrument RAVEN Reduce Avoidable Hospitalizations using Evidence-Based Interventions for Nursing Facilities program REIT real estate investment trust RN registered nurse SAPO state-authorized portable order SCTT Systems Change Tracking Tool SFF special focus facility SMI serious mental illness SNF skilled nursing facility SNFist skilled nursing facility specialist SNP special needs plan VA U.S. Department of Veterans Affairs VBP value-based payment VHA Veterans Health Administration WISH Act Well-Being Insurance for Seniors to be at Home Act PREPUBLICATION COPY—Uncorrected Proofs

Abstract Nursing homes play a unique dual role in the nation’s long-term care continuum, serving both as a place where people receive needed health care and a place they call home. Although long-term care is increasingly being provided in home- and community-based settings, nursing homes will likely always be needed for individuals who cannot get the level of care they require in those settings. The 1986 Institute of Medicine1 report Improving the Quality of Care in Nursing Homes described numerous con- cerns, including neglect and abuse of nursing home residents, poor quality of life, excessive cost, inconsistent (or lack of) oversight, and the need for high-quality data. While many improvements have been made since then, the enormous toll that the COVID-19 pandemic had on nursing home residents, their families, and staff has brought new attention to the long- standing shortfalls that continue to plague nursing homes. This report identifies critical opportunities to improve the quality of care in nursing homes through both short- and long-term actions across a wide variety of domains. Many recommendations will require dedi- cated coordination among federal and state governments, nursing homes, health care and social care providers, payers, regulators, researchers, and others as well as the active engagement of residents and their families. The nursing home sector urgently needs to be strengthened so that it can 1 As of March 2016 the Health and Medicine Division of the National Academies of Sci- ences, Engineering and Medicine (National Academies) continues the consensus studies and convening activities previously carried out by the Institute of Medicine (IOM). The IOM name is used to refer to reports issued prior to July 2015. xxv PREPUBLICATION COPY—Uncorrected Proofs

xxvi ABSTRACT respond effectively to the next public health emergency as well as drive critically important and urgently needed innovations to improve the qual- ity of nursing home care. Implementation of the committee’s integrated set of recommendations will move the nation closer to making high-quality, person-centered, and equitable care a reality for all nursing home residents, their chosen families, and the nursing home staff who provide care and support them in achieving their goals. PREPUBLICATION COPY—Uncorrected Proofs

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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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