The Committee on the Quality of Care in Nursing Homes was charged with examining the ways in which the United States currently delivers, finances, measures, and regulates the quality of nursing home care. After a thorough review of the evidence, the committee arrived at seven overarching conclusions.
First, the way in which the United States finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, fragmented, and unsustainable. Despite significant measures to improve the quality of care in nursing homes in the Omnibus Budget Reconciliation Act of 1987 (OBRA 87), too few nursing home residents today receive high-quality care. Moreover, too many nursing home workers, surveyors, and others do not receive adequate and appropriate support to fulfill their critical responsibilities. Furthermore, since 1987, the acuity level, comorbidity burden, and the sophistication and complexity of care needs of nursing home residents have increased markedly, but staffing requirements and regulations have not kept pace.
Second, the committee concluded that immediate action to initiate fundamental change is necessary. The situation in nursing homes was dire prior to the arrival of a new and extremely contagious viral infection. The COVID-19 pandemic amplified the significant long-standing weaknesses in nursing home care. Even prior to the pandemic, the quality of care in nursing homes was neither consistently comprehensive nor of high quality. Regulations in place for 35 years have not been fully enforced, further amplifying residents’ risk of harm. Those same shortcomings rendered nursing homes, their residents, and staff extremely vulnerable and unprepared to respond to the public health emergency. Heightened media attention on the disproportionate impact of the pandemic intensified demands for reform to
improve the quality of care in nursing homes. Significant actions to improve nursing home care can be implemented immediately; other needed changes will take longer to be fully operational, but need to be initiated now.
Third, the committee concluded that federal and state governments, nursing homes, health care and social care providers, payers, regulators, researchers, and others need to make clear a shared commitment to the care of nursing home residents. Indeed, the committee recognizes that no single actor or interested party will be able to ensure high-quality nursing home care on their own. Rather, fully realizing the committee’s vision will depend upon collaboration on the part of multiple public and private partners to honor this commitment to nursing home residents, their chosen families, and the staff who strive to provide the high-quality care every resident deserves.
Fourth, the committee emphasizes that extreme care needs to be taken to ensure that quality improvement initiatives are implemented using strategies that do not exacerbate disparities in resource allocation, quality of care, or resident outcomes (including racial and ethnic disparities), which are all too common in nursing home settings. Indeed, while the recommendations are intended to improve health equity, the committee cannot emphasize strongly enough the critical importance of close and systematic monitoring for potential unintended consequences.
Fifth, high-quality research is needed to advance the quality of care in nursing homes. Much of the available research relies on retrospective cohort designs and is constrained by limited available data on nursing home care. This lack of evidence presents challenges to determining the best approaches that will lead to improved quality of care in several areas.1
Sixth, the committee concluded that the nursing home sector has suffered for many decades from both underinvestment in ensuring the quality of care and a lack of accountability for how resources are allocated. Examples of inadequate investment include the following:
- Low staff salaries and benefits combined with inadequate training has made the nursing home a highly undesirable place of employment, made even worse in the pandemic.
- Inadequate support for oversight and regulatory activities has contributed to the failure of state survey agencies to meet their requirements in a timely manner.
- Quality measurement and improvement efforts have largely ignored the voice of residents and their chosen families.
- Lack of transparency regarding nursing home finances, operations, and ownership impedes the ability to fully understand how current resources are allocated.
While some reinvestment can come from increased efficiencies and improved payment policies, the committee acknowledges that the measures called for in the following recommendations will likely require significant investment of additional financial resources at the federal and state levels as well as from nursing homes themselves. However, the committee emphasizes that this investment should not be viewed as simply adding more resources to the nursing home sector as it currently operates, which would not likely result in significant improvements. Rather, the committee calls for targeted investments which, along with current funding, would be inextricably tied to requirements for transparency that are monitored through stronger and more effective oversight to ensure resources are properly allocated to improving the quality of care.
The committee recognizes that there is inherent tension when policy makers are faced with prioritizing areas of investment that require public funding. However, in order to achieve the committee’s vision of comprehensive high-quality care for all nursing home residents, the investment of new federal and state resources, as well as investment of resources from nursing homes themselves, will likely be needed. The committee also recognizes that key partners, such as the Centers for Medicare & Medicaid Services (CMS) and other federal agencies, may not currently have the full authority or resources to carry out the actions recommended. Therefore, as a final overarching conclusion, the committee notes that all relevant federal agencies need to be granted the authority and resources from the United States Congress to implement the recommendations of this report. Furthermore, as also noted earlier, the committee realizes that many of its recommendations will require key partners to work together among federal agencies and states as well as across sectors to implement these recommendations. This coordination of efforts will require regular communication to avoid duplication of efforts and to identify gaps in responses to pressing shortcomings in nursing home care.
As a framework for this study, the committee created an original conceptual model of high-quality care in nursing homes (see Chapter 1). The model depicts a vision of nursing home quality in which residents of nursing homes receive care in a safe environment that honors their values and preferences, addresses the goals of care, promotes equity, and assesses the benefits and risks of care and treatments.
In addition to this vision, the committee developed guiding principles for high-quality nursing home care that served to form the foundation for their recommendations (see Box 10-1).
While the committee’s vision identifies what high-quality nursing home care should look like, the guiding principles serve as a reminder of the very salient fact that existing regulations require nursing homes to provide comprehensive, person-centered care that is holistic and responds to a resident’s (and their chosen family’s) care needs, goals, and preferences. However, calling attention to the reality that person-centered care is not the standard of care in nursing homes today is critically important. CMS
emphasized the importance of this care in its 2016 revision of nursing home regulations, specifying that person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives.2 The regulations also require nursing homes to include resident preferences in the care plan. Existing regulatory requirements have not been fully or consistently met, however, with the result that high-quality, comprehensive, person-centered care is not being provided to all nursing home residents in the United States.
The committee’s goals (with associated recommendations)3 that follow represent an integrated approach for achieving its vision of high-quality nursing home care. The committee’s recommendations fall under seven critical goals:
- Deliver comprehensive, person-centered, equitable care that ensures residents’ health, quality of life, and safety; promotes autonomy; and manages risks.
- Ensure a well-prepared, empowered, and appropriately compensated workforce.
- Increase the transparency and accountability of finances, operations, and ownership.
- Create a more rational and robust financing system.
- Design a more effective and responsive system of quality assurance.
- Expand and enhance quality measurement and continuous quality improvement.
- Adopt health information technology in all nursing homes.
Consistent with the broad charge of the committee, the committee’s approach to improving the quality of care in nursing homes identifies opportunities for change in a broad range of areas encompassing care delivery—from changes to the physical environment and strengthening emergency preparedness to enhancing the workforce; strengthening the payment, financing, and regulatory policy environments; improving quality measurement; and ensuring the adoption of an effective health information technology (HIT) infrastructure to support all the committee’s recommendations.
2 CMS Requirements for Long-Term Care Facilities—Definitions, 42 CFR § 483.5 (2022).
Improving the quality of care in nursing homes is not only possible but also represents a critical societal and public health imperative. Achieving each of the committee’s goals will entail significant revisions to how care is delivered, financed, and regulated and how its quality is measured and improved, which requires a broad-based commitment to change from owners and administrators, staff, health care providers and organizations, researchers, and policy makers. Leveraging the expertise, leadership, and influence of this broader community will advance necessary changes.
Though the recommendations focus on diverse areas for improvement, they are interlinked by an underlying premise: the challenges facing nursing homes are complex and multifaceted and require urgent attention on multiple fronts by many participants in the system. Some recommendations are intentionally broad, allowing flexibility in how they are implemented, while others are more targeted, with more specific details on how to achieve the objectives. Some can be implemented in the near term, while others will require a longer time line; some should be relatively straightforward to achieve, while others are more aspirational and will require coordinated efforts to create significant long-term changes. The committee’s recommendations should be viewed and implemented as an interrelated package of reform measures. (See Appendix E for the committee’s estimated implementation time line.)
Overview of Recommendations
Nursing home residents and their families are at the heart of the committee’s conceptual model, and all recommended actions are designed to improve the quality of care and quality of life for those who live in nursing homes. The committee’s first goal (and first recommendation) affirms person-centered care by focusing on the identification of resident preferences and the use of the care plan. Person-centered care is enabled through the development and implementation of an accurate and effective care plan that reflects the individualized needs, preferences, and goals of care of each nursing home resident.
The committee recognizes that this first recommendation, which underscores the vital role of the care plan, may not be innovative; it is already required by federal law. However, the committee intentionally and strategically placed the goal of delivering comprehensive person-centered care first to serve as the foundation that subsequent recommendations build upon. This primary focus on person-centered care is critical to the provision of high-quality care in nursing homes and bears emphasis and reinforcement because, all too often, such care is not being provided to nursing home residents. The committee’s foundational goal also calls for improvements
to the physical environment of nursing homes and supports the goal of establishing smaller, less institutionalized nursing homes. Given the impact of the pandemic, the committee also calls for strengthening the preparation of nursing homes for public health emergencies.
The recommendations gradually build upon the solid foundation of Goal 1. The next set of recommendations focuses on the workforce that supports and cares for residents and the myriad staffing-related factors in urgent need of attention, such as compensation, education and training, and staffing patterns (Goal 2). This is followed by a focus on increasing the transparency and accountability of finances, operations, and ownership (Goal 3). From there, the recommendations’ focus continues to broaden, moving to the development of a more rational and robust system of financing nursing home care, including the committee’s call for the study of a federal long-term care benefit and targeted measures to strengthen the link between payment and the quality of care (Goal 4). Underscoring the importance of linking funding to transparency and accountability, the committee calls for enhanced measures to ensure an effective and responsive system of quality assurance through strengthened oversight and regulation of nursing homes (Goal 5). Expanding and enhancing quality measurement and quality improvement across all aspects of care provision (Goal 6), and including the voices of nursing home residents and their chosen families in these efforts, will be a critical component of strengthening quality assurance. HIT plays a key role in implementing all the committee’s recommended actions, from improving care planning and quality measurement and assessment, to supporting the delivery of high-quality care and enabling the secure sharing of resident information between nursing homes and hospitals and other health care settings (Goal 7). Finally, the committee emphasizes the vital importance of attention to health equity and measures to reduce inequities in nursing home care, which is woven throughout its recommendations.
GOAL 1: DELIVER COMPREHENSIVE, PERSON-CENTERED, EQUITABLE CARE THAT ENSURES RESIDENTS’ HEALTH, QUALITY OF LIFE, AND SAFETY; PROMOTES AUTONOMY; AND MANAGES RISKS
While person-centered care is foundational to the basic requirements of federal law and regulations of nursing home care, such care is not yet a reality for many nursing home residents. Significant gaps and shortcomings exist in the quality of services such as behavioral health and psychosocial care as well as in vision, hearing, and oral health care and end-of-life care. Moreover, significant disparities in the quality of care exist across nursing homes.
In considering the most effective approaches to fully realizing person-centered, comprehensive, high-quality and equitable care in practice in the nursing home setting, the committee recognized the central role of the resident care planning process. The resident care planning process provides a very firm foundation for operationalizing person-centered, high-quality, equitable care in nursing homes. The care plan process encompasses four critical components: creating the plan, reviewing the plan, implementing and subsequently evaluating the effectiveness of the plan, and revisiting and reviewing the care plan on a regular basis. Ideally, all of the components of the process will be implemented effectively in every nursing home. The committee recognizes that despite the critical role of the care planning process, this ideal has yet to become a reality in all nursing homes.
The first step in the process is the development of the care plan through the use of the Minimum Data Set Resident Assessment Instrument (RAI) and a shared decision-making process with residents and their chosen families to explore and identify resident care needs and preferences. These needs and preferences are then documented in the written care plan, which serves as a critical road map for care targeted to the specific goals of the individual resident: the essence of person-centered care.
Second, the care plan needs to incorporate the broad range of each resident’s care needs, from physical and behavioral health to activities of daily living and preferences (e.g., attending a religious service, favorite television shows, trips to the hairdresser). To ensure that the care plan is accurate and comprehensive, members of the interdisciplinary care team need to be directly involved in reviewing and evaluating all aspects of the care plan, working together with residents and their family members. Nursing home requirements updated by CMS in 2016 specify the members of the interdisciplinary care team (detailed in Box 4-2, Chapter 4). Given the critical importance of the review and evaluation of the care plan, the committee emphasizes that this step should be overseen by nursing staff at least at the level of the registered nurse (RN).
Third, once the plan is reviewed by the interdisciplinary care team and deemed to be accurate and complete, the plan needs to be implemented. Each element of the care plan needs to include specific measures for assessing the progress of implementation and whether desired results are being achieved (degree and timing).
Fourth, in recognition of the changing nature of resident needs and preferences and of physical and mental health conditions, the care plan is to be reviewed on a regular basis. This review should take place quarterly or at the request of a resident or family member, or when there is a significant change in resident’s status (as specified in the RAI manual) to ensure
that the plan continues to align with resident and family preferences over time.
Recognizing the central role of the care plan as a means to achieve person-centered comprehensive, high-quality, equitable care, and fully cognizant of the fact that many of the actions recommended below are already required by federal law, the committee recommends the following:
RECOMMENDATION 1A: As a critical foundation to operationalizing person-centered care that reflects resident goals and preferences, the committee recommends compliance with regulations for person-centered care. Nursing homes,4 with oversight by CMS, should
- Identify the care preferences of residents and their chosen families using structured, shared decision-making approaches that balance resident preferences for safety and autonomy.
Ensure that resident care preferences are accurately documented in the care plan.
- Interdisciplinary care team members should make certain that every resident’s care plan addresses psychosocial and behavioral health as well as nursing and medical needs.
- To certify that all aspects of the resident’s care needs are fully addressed in the care plan, the interdisciplinary care team should review and evaluate the care plan to ensure it is complete, with oversight of the review and evaluation process provided by nursing staff at least at the level of the RN.
- A complete plan should include evaluation steps (i.e., specific measures and timing of measurement) to assess the degree of implementation and success of each element.
Implement and monitor each element of every resident’s care plan and evidence of effective implementation to ensure that the care delivered continues to align with the resident’s preferences.
- Nursing home staff should revisit the care plan on a regular basis for all residents—at a minimum on a quarterly basis, when requested by the family/resident, or when there has been a significant change in condition as specified in the Long-Term Care Facility Resident Assessment Instrument 3.0 Users’ Manual.
4 While the committee calls on nursing homes to implement many of its recommendations, it recognizes that it is the individual nursing home owners, administrators, and clinical leaders who need to be held accountable for the quality of care provided within their specific organizations. The active role of these individuals is necessary to ensure the committee’s recommendations are put into place.
Models of Care
Nursing homes are required by law to provide an array of services to both short-stay and long-stay residents of all ages with a wide range of medical and behavioral health conditions. Yet despite the complexity of the care challenges faced by nursing homes, research on best practices related to clinical, behavioral, and psychosocial care delivery in nursing homes is scarce. As a result, a robust evidence base has not yet been developed for specific models of care delivery that could serve as the most effective approach to providing high-quality person-centered care to all nursing home residents while ensuring equitable care. Given these critical knowledge gaps, the committee calls out federal agencies as well as private foundations, academic institutions, and others to prioritize and fund research on effective care delivery models.
Moreover, nursing homes are often not well connected to the communities in which they are located, nor to the broader health care system. Research that examines models of care that strengthen ties to the broader community, including universities and all sectors of the health care system, is needed to improve these connections. Finally, research on care delivery needs to focus on the specific factors that affect care directly, such as optimal staffing, physical environment, financing and payment, the use of technology, leadership models, and organizational policy. Once research has successfully identified the most effective care models, this research should be translated into practice by launching demonstration projects to test specific models in nursing home settings. The projects should be designed with an eye toward sustainability. Therefore, the committee recommends the following
RECOMMENDATION 1B: The federal government (e.g., the Agency for Healthcare Research and Quality [AHRQ], CMS, the Center for Medicare and Medicaid Innovation, the Centers for Disease Control and Prevention, and the National Institutes of Health [NIH]), private foundations, academic institutions, and long-term care provider organizations should prioritize and fund rigorous, translational research and demonstration projects to identify the most effective care delivery models to provide high-quality comprehensive, person-centered care for short-stay and long-stay nursing home residents.
- This research should focus on identifying care delivery models that reduce care disparities and strengthen connections among the nursing homes, the communities in which they are located, and the broader health care and social services sectors.
- Research on care delivery models should evaluate innovations in all aspects of care, including optimal staffing, physical environment, financing and payment, the use of technology, leadership models, and organizational policy.
Emergency Preparedness and Response
The COVID-19 pandemic shone a light on the extremely harsh lack of preparedness on the part of nursing homes for a large-scale public health emergency. Prior to the COVID-19 pandemic, there were numerous examples of nursing homes being unprepared to respond to a range of emergencies and natural disasters, such as hurricanes, tornadoes, earthquakes, floods, and wildfires. In order for nursing homes to have the capability to plan and prepare for and respond to all types of emergencies, they need to be included as integral partners in emergency management planning, preparedness, and response on the national, state, and local levels. Moreover, nursing homes need not only to be prepared to provide for the physical safety of residents but also to address their behavioral and psychosocial needs during emergencies. As demonstrated by the prohibition against friend and family member visitation during the COVID-19 pandemic and the resultant harm of social isolation, it is imperative to strike a careful balance between residents’ safety and their mental and behavioral health needs. Therefore, the committee recommends the following:
RECOMMENDATION 1C: In order to safeguard nursing home residents and staff against a broad range of potential emergencies, the Department of Homeland Security should direct the Federal Emergency Management Agency to reinforce and clarify the emergency support functions (ESFs) of the National Response Framework. Specifically,
- ESF 8 (Public Health and Medical Services) should be revised to give greater prominence to nursing homes with the goal of clarifying that nursing homes specifically, and long-term care facilities more broadly, are included within ESF 8 (Public Health and Medical Services) to ensure that state and local emergency management documents and plans contain specific guidance for nursing homes during an emergency.
- ESF 15 (External Affairs Annex) should be revised to specifically include residents of nursing homes as part of the target group of “individuals with disabilities and others with access and functional needs.”
Local, county, and state-level public health agencies need to ensure that nursing homes “have a seat at the table.” This can be accomplished through the development of formal relationships and by ensuring reliable lines of communication. In addition, nursing homes are not always included in all phases of emergency management, such as drills and exercises. Finally, while nursing homes are currently required to have written
emergency plans created in partnership with local emergency management, to review and update the plan on a regular basis, and to provide staff training in critical aspects of emergency planning, these requirements are not always in place or enforced. Therefore, the committee recommends the following:
RECOMMENDATION 1D: To ensure the physical safety as well as address behavioral health/psychosocial needs of nursing home residents and staff in public health emergencies and natural disasters,
- State regulatory agencies (with federal oversight from the Federal Emergency Management Agency and CMS) should ensure the development and ongoing maintenance of formal relationships, including strong interface, coordination, and reliable lines of communication, between nursing homes and local, county, and state-level public health and emergency management departments.
State emergency management agencies should make certain that nursing homes are represented in
- state, county, and local emergency planning sessions and drills;
- local government community disaster response plans; and
- every phase of the local emergency management planning including mitigation, preparedness, response and recovery.
- State emergency management agencies should ensure that every nursing home has ready access to personal protective equipment (PPE).
CMS (through state regulatory agencies) is to ensure that existing regulations are enforced, including the following:
- Nursing home leadership ensures that there is a written emergency plan (including evacuation plans) for common public health emergencies and natural disasters in the facility’s location, which is created in partnership with local emergency management and resident and family councils.
Nursing home leadership reviews and updates the plan at least once every year.
- Nursing home staff are to be routinely trained in emergency response procedures and periodically review procedures.
- Nursing home staff are to be routinely trained in the appropriate use of PPE and infection control practices.
- Nursing home leadership ensures that there is an emergency preparedness communication plan that includes formal procedures for contacting residents’ families and staff to provide information about the general condition and location of residents in the case of an emergency or disaster.
- Documentation concerning emergency plans as well as of the conduct of emergency drills and staff awareness of emergency management plans should be added to Care Compare.
The committee emphasizes that CMS needs to ensure that staff receive training in critical aspects of emergency planning upon being hired (e.g., during staff orientation) and need to receive periodic training to refresh and update their skills and knowledge.
It is critical to recognize that nursing homes serve dual roles: care settings as well as places in which people reside. All aspects of the nursing home’s physical environment are critical to a resident’s quality of life, yet most nursing homes resemble institutions more than homes. The nursing home infrastructure is aging, with the majority of nursing homes at least 30 years old and many of them 50 years or older, and therefore, the homes may not reflect the needs and preferences of today’s older adults for smaller, home-like units. Smaller, home-like environments (including single-occupancy bedrooms and private bathrooms) provide important benefits for residents and staff and play key roles in infection control as well as an enhanced quality of life for residents. The committee recognizes that these changes will require significant investment, and concluded that design changes can be operationalized through federal incentives and state licensure decisions. Therefore, the committee recommends the following
RECOMMENDATION 1E: Nursing home owners, with the support of federal and state governmental agencies, should construct and reconfigure (renovate) nursing homes to provide smaller, more home-like environments and/or smaller units within larger nursing homes that promote infection control and person-centered care and activities.
The design of these nursing homes should include consideration for the following characteristics: unit size, activity and dining space by unit, a readily accessible therapeutic outdoor area, an open kitchen, a staff work area, and entrances and exits.
- Smaller units should be designed to have the flexibility to address a range of resident care and rehabilitation needs.
- New designs should prioritize private bedrooms and bathrooms.
- This shift to more home-like settings should be implemented as part of a broader effort to integrate the principles of culture change, such as staff empowerment, consistent staff assignment, and person-centered care practices, into the management and care provided within these settings.
- CMS, the U.S. Department of Housing and Urban Development, and other governmental agencies should develop incentives to support designs for nursing home environments (both new construction and renovations).
- State licensure decisions should ensure that all new nursing homes are constructed with single-occupancy bedrooms and private bathrooms for most or all residents.
In 2008, the Institute of Medicine (IOM) report Retooling for an Aging America noted that while the need for health care professionals trained in geriatric principles was escalating, few providers choose this career path due to a variety of factors, including inadequate education and training, negative stereotypes of older adults, and significant financial disincentives to working in geriatrics. The report further noted that these issues may be especially significant for long-term care settings. The culture within nursing homes, as well as how the public views both aging in general and nursing homes specifically, will need to change because high-quality care cannot be delivered without a complete transformation of worker training and social stature. These changes to the culture of nursing homes need to be driven by nursing home leaders to ensure a robust, high-quality workforce. The following recommendations provide a variety of ways to ensure that the nursing home workforce is respected, well prepared, empowered, and appropriately compensated.
The committee recommends increasing both the numbers and the qualifications of virtually all types of nursing home workers, along with providing the necessary incentives and supports to achieve these changes. The committee recognizes that increasing requirements can exacerbate the challenges of recruiting nursing home workers. This is particularly concerning given the current dire staffing situations for many nursing homes, largely due to the impact of the COVID-19 pandemic. The committee concluded, however, that robust evidence demonstrates the positive impact of enhanced requirements on the quality of care. Moreover, enhanced requirements will further professionalize the nursing home workforce, which, when accompanied by improvements in the working environment, will contribute to the desirability of working in a nursing home.
Nursing home workers earn significantly less in nursing homes than if they chose to work in other care settings. For example, according to
2020 data from the Bureau of Labor Statistics, the annual mean wage for RNs in nursing homes is approximately $10,000 less (more than 10 percent less) than RNs in acute-care hospitals and $17,000 less (nearly 20 percent less) than RNs employed in outpatient care settings. In particular, certified nursing assistants (CNAs) typically earn low wages and have few benefits; as a result, many live in poverty or require public assistance. The 2020 mean hourly wage for CNAs in nursing homes was $15.41 and the mean annual wage was $32,050. CNAs may earn little more than workers in other comparable entry-level jobs (such as cashier, food service worker, warehouse worker, and retail sales worker), who may have lower levels of risks for injury and may even receive full benefits.
The committee concluded that the successful recruitment and retention of a high-quality nursing home workforce depends on providing more than “adequate” compensation for their work. Rather, competitive compensation is needed (comparable to other health care settings and job opportunities) for their current and expanding roles in conjunction with the many different types of efforts that will be needed to improve the desirability of these jobs. A variety of mechanisms have been tried to increase workers’ compensation and benefits, and different mechanisms may be needed to achieve competitive compensation. Therefore, the committee recommends the following:
RECOMMENDATION 2A: Federal and state governments, together with nursing homes, should ensure competitive wages and benefits (including health insurance, child care, and sick pay) to recruit and retain all types of full- and part-time nursing home staff. Mechanisms that should be considered include wage floors, requirements for having a minimum percentage of service rates directed to labor costs for the provision of clinical care, wage pass-through requirements, and student loan forgiveness.
The committee recognizes that the provision of benefits may encourage some nursing homes to reduce staffing levels or hire part-time rather than full-time staff. The committee emphasizes that nursing homes need to offer full-time, consistently assigned work whenever it is possible and desired by the worker in order to ensure high-quality care.
Staffing Standards and Expertise
Minimum staffing standards in nursing homes, particularly for licensed nursing staff, have been evaluated for decades. In 2001, CMS studied the minimum appropriate staffing levels, using modeling to identify a staffing threshold below which residents are at risk for serious quality-of-care issues. However, to date the proposed CMS minimum staffing standards have not been addressed in any subsequent regulatory rules, leaving stand
a vague nurse staffing requirement that nursing homes must provide “. . . sufficient nursing staff to attain or maintain the highest practicable . . . wellbeing of each resident.” Substantial evidence demonstrates the relationship between nurse staffing and quality of care in nursing homes, particularly for RNs. The 1996 IOM report Nursing Staff in Hospitals and Nursing Homes recommended a requirement for 24-hour RN coverage in nursing homes by the year 2000. The recommendation was endorsed by a subsequent IOM study in 2001, and then recommended again in the 2004 IOM report Keeping Patients Safe. Yet today the federal requirement is a 24-hour daily presence of licensed nurse coverage with an RN fulfilling only 8 of those hours.
Furthermore, CMS has not established minimum staffing requirements for certain key members of the interdisciplinary nursing home care team. Social workers, for example, contribute to resident care and take on various complex and clinically challenging responsibilities. Social work interventions in nursing homes have been associated with significant improvements in residents’ quality of life, yet current federal regulations require only those nursing homes with 120 or more beds to hire a “qualified social worker on a full-time basis.” Moreover, the “qualified social worker” is not required to hold a degree in social work, despite research showing that having social service staff members in nursing homes with higher qualifications is associated with better psychosocial care, improved behavioral symptoms, and reduced use of antipsychotic medications.
Additionally, as part of CMS’s 2016 final rule, nursing homes are required to designate at least one part-time or full-time staff member as the infection prevention and control specialist. The final rule suggested that an RN would assume the role of the infection prevention and control specialist in most facilities and that the individual would need to devote approximately 15 percent of his or her time to this role. The CMS Coronavirus Commission on Safety and Quality in Nursing Homes noted, however, that the current regulations yielded an “insufficient response to the demands” of COVID-19.
The committee concluded that current minimum staffing requirements are insufficient as they relate to RN coverage, social worker presence, and infection and prevention control. Therefore, the committee recommends immediate implementation of the following minimum staffing requirements:
RECOMMENDATION 2B: CMS should enhance the current minimum staffing requirements for every nursing home to include
- Onsite direct-care RN coverage (in addition to the director of nursing) at a minimum of a 24-hour, 7-days-per-week basis with additional RN coverage that reflects resident census, acuity, case mix, and the professional nursing needs for residents as determined by the residents’ assessments and care plans;
- A full-time social worker with a minimum of bachelor’s degree in social work from a program accredited by the Council on Social Work Education and 1 year of supervised social work experience in a health care setting (including field placements and internships) working directly with individuals to address behavioral and psychosocial care; and
- An infection prevention and control specialist who is an RN, advanced practice RN, or a physician at a level of dedicated time sufficient to meet the needs of the size and case mix of the nursing home.
Increasing RN staffing and overall nurse staffing in nursing homes has been a consistent recommendation for improving the quality of care in nursing homes. However, the same federal staffing regulations have been in place for over 30 years, even though the types of residents and the complexity of their needs have changed dramatically. Federal staffing requirements do not specify adjustments based on the size of the nursing home or resident acuity. The committee concluded that the current minimum staffing standards likely do not reflect the needs of the current population of nursing home residents and that more research is needed on both the minimum and optimal staffing standards to meet the needs of today’s nursing home population. Such information is needed for all types of nurses, including advanced practice RNs (APRNs), RNs, licensed practical/vocational nurses (LPNs/LVNs), and CNAs as well as other staff who support the health and well-being of nursing home residents. Therefore, the committee recommends the following:
RECOMMENDATION 2C: The U.S. Department of Health and Human Services (HHS) (e.g., CMS, AHRQ, and NIH) should fund research to identify and rigorously test specific minimum and optimum staffing standards for direct-care staff (e.g., APRNs, RNs, LPN/LVNs, CNAs, therapists, recreational staff, social workers, and other direct-care providers), including weekend and holiday staffing, based on resident case mix and the type of staff needed to address the care needs of specific populations. Based on the results of this research, CMS and state governments should update the regulatory requirements for staffing standards in nursing homes to reflect new minimum requirements and account for case mix.
While nursing homes may meet minimum staffing standards, additional expertise is often needed to provide comprehensive, person-centered care. Such additional expertise is especially needed for the development of complex clinical care plans, staff training, and overall planning for care systems and quality improvement. Not every facility will have the ability or need
to keep such expertise on staff. The committee concluded that nursing homes need to develop ongoing relationships with a variety of professionals who can provide consultation on an as-needed basis. Access to this level of expertise is also limited by barriers to direct billing and reimbursement for these professional services. Therefore, the committee recommends the following:
RECOMMENDATION 2D: To enhance the available expertise within a nursing home,
- Nursing home administrators, in consultation with their clinical staff, should establish consulting or employment relationships with qualified licensed clinical social workers at the M.S.W. or Ph.D. level, APRNs, clinical psychologists, psychiatrists, pharmacists, and others for clinical consultation, staff training, and the improvement of care systems, as needed.
- CMS should create incentives for nursing homes to hire qualified licensed clinical social workers at the M.S.W. or Ph.D. level as well as APRNs for clinical care, including allowing Medicare billing and reimbursement for these services.
The committee notes that many other types of experts may be needed, depending upon the acuity and case mix of the nursing home residents and the availability of such expertise among the nursing home’s own staff, including professionals such as dentists, audiologists, physical and occupational therapists, and many others. Furthermore, the committee recognizes that allowing direct billing for certain services would require an expansion of the Medicare program, as was called for in the 2011 IOM report The Future of Nursing.
Direct-care workers (primarily CNAs) provide the majority of hands-on care to nursing home residents. Such care includes everyday tasks such as assistance with eating, bathing, toileting, and dressing as well as more advanced tasks such as infection control and care of cognitively impaired residents. Tailoring these tasks to residents’ preferred schedules and needs is critical to meeting residents’ goals and maintaining their function, well-being, and quality of life. The demand for CNAs is increasing, yet nursing homes have persistent challenges in recruiting and retaining workers. The top reasons for direct-care workers leaving their jobs include a lack of respect and appreciation by leadership, inadequate salary and benefits, a lack of teamwork and communication among the staff, and poor relationships with supervisors, residents, and families. CNAs may be undervalued or not respected by other
nursing home staff or leadership, and their responsibilities put them at high risk for injury. Furthermore, CNAs often have little opportunity for advancement. Because of the crucial role of this position in nursing homes, the committee concluded that significantly improving the quality of care for nursing home residents requires investing in quality jobs for direct-care workers and enabling more workers to enter the CNA pipeline. Therefore, in addition to the recommendation for ensuring competitive wages and benefits (Recommendation 2A), the committee recommends the following:
RECOMMENDATION 2E: To advance the role of and empower the CNA,
- Nursing homes should provide career advancement opportunities and peer mentoring;
- Federal and state governments, together with nursing homes, should enable free entry-level training and continuing education (e.g., in community colleges);
- Nursing homes should cover CNAs’ time for completing education and training programs; and
- The Health Resources and Services Administration should fund training grants to advance and expand the role of the CNA and develop new models of care delivery that take advantage of the role of the CNA as a member of the interdisciplinary care team.
Education and Training
In addition to improving wages and strengthening staffing standards, the education and training of the entire nursing home workforce is key to improving the quality of care in nursing homes. Education and training requirements for a variety of nursing home staff are inadequate or nonexistent. For example, the requirements for licensure as a nursing home administrator vary by state, and about one-third of states do not even require a bachelor’s degree to be a nursing home administrator. Medical directors need to have a license to practice medicine in the state, but there are no additional specific education and training or certification requirements at the national level. The director of nursing is required to be an RN (although there are waivers to this requirement), and the competencies needed by directors of nursing often exceed the preparation provided in either associate degree or baccalaureate degree nursing programs. Both the medical director and the director of nursing have key roles in infection prevention and control, yet they may not receive specific training in these skills. The director of social services oversees all social service programs and supervises social workers and social service designees within the facility, yet there typically are no formal requirements for the role. Finally, CNAs are often inadequately prepared and trained for their expanding role. The 2008
IOM report Retooling for an Aging America recommended increasing the federal training requirement for direct care workers (including CNAs) to 120 hours, based on the significant number of states that require training beyond the federal minimum. While some states have increased their requirements since then, the federal minimum has remained unchanged. The training standards and curricula for direct-care workers are dated and focus on basic tasks rather than on competencies to meet the needs of today’s nursing home residents.
The committee concluded that the minimum education and competency requirements need to be enhanced (or established) for a variety of nursing home workers and to be made standard at the national level. The committee recognizes that many current nursing home workers may not meet these new requirements and may need assistance in achieving these standards. Additionally, the committee recognizes that increasing the education and training requirements of these personnel can exacerbate the challenges of recruiting nursing home workers. However, as noted earlier, the committee concluded that robust evidence supports these enhanced requirements because of their impact on the quality of care. Finally, the committee recognizes that a key issue underlying the preparation of all types of workers for nursing home care is the inadequate foundation for a variety of geriatrics-related topics in their education and training programs. Therefore, the committee recommends the following:
RECOMMENDATION 2F: CMS should establish minimum education and national competency requirements for nursing home staff, to include
- Nursing home administrator: minimum of a bachelor’s degree and training in topics relevant to their role (e.g., culture change, leadership and team-building, administration, and financial management);
- Medical director: completion of education or certification program specific to the care of older adults and certification in infection control and prevention;
- Director of nursing: minimum of a bachelor’s degree in nursing, with a preference for master’s level training; training in geriatrics and long-term care; and certification in infection control and prevention;
- Director of social services: minimum of a bachelor’s degree in social work from a program accredited by the Council on Social Work Education (CSWE), with a preference for master’s level training from a program accredited by CSWE; and
- Certified nursing assistants: an increase in the federal minimum of training hours to become a certified nursing assistant from 75 hours to 120 hours and training content that includes competency-based training requirements.
CMS and nursing homes should give special consideration for current staff members who do not meet these enhanced requirements and provide flexible, low-cost, and high-quality pathways to achieve these baseline education and competency levels.
Furthermore, to prepare future workers for their roles, all education programs preparing health care professionals should include content related to gerontology, geriatric assessment, long-term care, and palliative care, with an additional preference for clinical experience in a nursing home.
Regarding the recommendation for competency-based training for certified nursing assistants, the committee notes that specific instruction is needed for conditions and topics relevant to nursing home populations (beyond basic care) such as dementia; infection prevention and control; behavioral health; chronic diseases such as diabetes, heart failure, and chronic obstructive pulmonary disease; the use of assistive and medical devices; and cultural sensitivity and humility.
In addition to these enhanced requirements, the committee concluded that efforts are needed to augment the education, training, and competency of the nursing home workforce on an ongoing basis. Many nursing home workers have no requirements for continuing education related to national competencies (and when such requirements exist, they generally vary by state). Furthermore, there are substantial differences in the types of jobs that racial and ethnic minority workers are sorted into within the nursing home workforce, which can affect power hierarchies within the workforce as well as compensation and benefits. In addition, nursing home residents are becoming increasingly diverse in terms of racial and ethnic groups, LGBTQ+ populations, and younger populations, yet little is known about their specific care needs in the nursing home setting or their preferences for who cares for them. As a result, the committee concluded that all nursing home workers would benefit from specific workforce-related education and training in principles of diversity, equity, and inclusion as well as cultural sensitivity and humility with respect to institutional factors such as biases (e.g., hiring, pay, and promotion practices), cultural factors (e.g., discrimination, micro-aggressions), and interpersonal factors (e.g., racial biases). Training is also needed for the needs of younger populations in nursing homes as well as training in principles of diversity, equity, and inclusion related to the unique, culturally sensitive care needs of specific populations (e.g., LGBTQ+, specific racial and ethnic groups). For example, as noted in Chapter 2, the LGBTQ+ community may face harassment and abuse in nursing homes, and efforts to improve the quality of care for this population of nursing home residents include enhanced staff training in LGBTQ+affirming care. Finally, the committee recognizes that family caregivers are
an essential and valued part of the nursing home workforce and often do not receive the support and training they need to be effective members of the care team. Therefore, the committee recommends the following:
RECOMMENDATION 2G: To enhance the education and training of the entire nursing home workforce,
- CMS should require all levels of nursing home staff to complete annual continuing education training to ensure that staff members are meeting national competency standards.
- Nursing homes should provide ongoing diversity and inclusion training (e.g., self-awareness of and approaches to addressing racism) for all workers and leadership and ensure that the training is designed to meet the unique demographic, cultural, linguistic, and transportation needs of the community in which the nursing home is situated and the community of workers within the nursing home.
- Nursing homes should provide family caregivers with resources, training, and opportunities to participate as part of the caregiving team in the manner and to the extent that residents desire their chosen family members to be involved.
Regarding opportunities to provide improved and expanded education and training experiences for nursing home staff, the committee recognizes that programs may not exist that are specific to the nursing home setting. Therefore, this is a prime opportunity for foundations, researchers, and others to develop training programs for staff and families specific to the nursing home setting.
Data Collection and Research
In addition to enhanced requirements for key leaders and workers in nursing homes, there is a need to increase the overall numbers of more highly trained professionals (e.g., physicians, APRNs, physician assistants) involved in the delivery of care in nursing homes. However, the committee found that little is known about the prevalence of these types of workers in nursing homes and the extent of their training and expertise. The committee particularly noted a dearth of information about the role, staffing patterns, and training of medical directors, social workers, physicians, APRNs, and physician assistants. Additionally, few data exist for the numbers and staffing patterns for contract and agency staff providing care in nursing homes. This is largely due to the fact that many of these care providers are not currently captured in data reported to CMS, most notably because many of them are not directly employed by the nursing home. Finally, the committee found that very little is known about the baseline demographic information
for several key members of the nursing home leadership, including medical directors, administrators, and directors of nursing. The committee concluded that much more detailed information is needed about a variety of professionals working in nursing homes in order to better understand their expertise, numbers, and staffing patterns across facilities. Furthermore, while evidence exists on the association between APRNs and the quality of care in nursing homes, baseline data are needed for a variety of professionals to more fully assess their impact on the quality of care for nursing home residents and, ultimately, to determine their minimum and optimum staffing levels (as well as innovative staffing models) to provide high-quality care for nursing home residents. Therefore, the committee recommends the following:
RECOMMENDATION 2H: As a part of routine (e.g., at least annual) data collection, nursing homes should collect and report data to CMS regarding
- Baseline demographic information on medical directors, administrators, and directors of nursing, including name, licensure, contact information, and tenure in their position;
- The geriatrics or long-term care training, expertise, and staffing patterns (including time providing direct care) of medical directors, APRNs, social workers, physicians, and physician assistants providing services in nursing homes; and
- The numbers and staffing patterns (including time providing direct care) for all contract and agency staff providing services in nursing homes.
The committee notes that some of these data may be able to be captured through the Payroll Based Journal reporting system, while other information will need to be captured in other ways.
As noted earlier, the recruitment and retention of all types of nursing home workers has significant challenges. While many of the barriers to recruitment and retention are known, the committee concluded that more research is needed on persistent systemic barriers, including the influence of systemic and structural racism that has created and sustained racial and ethnic disparities among long-term care workers. Therefore, the committee recommends the following:
RECOMMENDATION 2I: HHS (e.g., CMS, AHRQ, and NIH) should fund research on systemic barriers and opportunities to improve the recruitment, training, and advancement of all nursing home workers, with a particular focus on CNAs. This research should include the collection of gender-, ethnicity-, and race-related outcomes of job quality indicators (e.g., hiring, turnover, job satisfaction).
A key aim of nursing home oversight over the past decade has been to ensure greater transparency into finances, operations, and ownership. CMS makes some ownership information available for active nursing homes, but these data are incomplete, difficult to verify, and often difficult to use. Current data sources do not allow for the determination of corporate structure, finances, and operations of individual facilities. Furthermore, the increased complexity of nursing home ownership structures complicates the ability to understand where nursing homes spend their resources and the ability to gain a more accurate sense of their financial well-being and spending priorities. Moreover, there is currently little transparency regarding the practice of some nursing homes to contract with related-party organizations (those also owned by the nursing home owners) for services such as management, nursing, or therapy.
Progress has been made in simplifying nursing home cost reporting in recent years, yet there are still substantial questions about the accuracy and completeness of these data. For example, there is no current mechanism to audit the accuracy and completeness of reported data, and requirements related to the full disclosure of ownership have not been enforced. In 2016, the U.S. Government Accountability Office (GAO) found that while CMS collects and reports expenditure data, it “has not taken key steps to make the data readily accessible to public partners or to ensure their reliability.” The committee concluded that increased transparency and accountability of the data on the finances, operations, and ownership of all nursing homes are needed for a variety of purposes. In particular, this is important for improving the financial investment in nursing home care as well as for improving regulatory oversight, all toward a common goal of improving the quality of care in nursing homes. Therefore, the committee recommends that, at the level of the individual facility,
RECOMMENDATION 3A: HHS should collect, audit, and make publicly available detailed facility-level data on the finances, operations, and ownership of all nursing homes (e.g., through Medicare and Medicaid cost reports and data from Medicare’s Provider Enrollment, Chain, and Ownership System).
- HHS should ensure that the data allow the assessment of staffing patterns, deficiencies, financial arrangements and payments, related party entities, corporate structures, and objective quality indicators by common owner (i.e., chain and multifacility owners) and management company.
Once such data are available in a manner that allows for the assessment of quality by common owner or management company, the committee recommends the following:
RECOMMENDATION 3B: HHS should ensure that accurate and comprehensive data on the finances, operations, and ownership of all nursing homes are available in a real-time, readily usable, and searchable database so that consumers, payers, researchers, and federal and state regulators are able to use the data to
- Evaluate and track the quality of care for facilities with common ownership or management company, and
- Assess the impact of nursing home real estate ownership models and related-party transactions on the quality of care.
The committee’s recommendations are designed to target the well-known shortcomings related to financing nursing home care in the United States. Characterized by a high degree of fragmentation, the current approach to financing nursing home care is not an intentional system, but rather a set of circumstances that has evolved over time to fill the largest gaps. Medicaid plays a dominant role as the default payer of nursing home care, but the federal–state program is constantly subject to state budget constraints. Medicare revenues from post-acute care play a disproportionate role in financial sustainability of nursing home care, and services such as hospice care are paid separately and are not well integrated into standard nursing home care. Private insurance is rare, and few people can pay out of pocket for an extended nursing home stay.
One implication of this unsystematic financing arrangement is a lack of equity in access to high-quality nursing home care. Heavy reliance on Medicaid to fund nursing home care, with strict financial and health-related eligibility rules, results in situations in which individuals may go without needed care or receive care that is inadequate in quality or quantity. A large body of literature shows that dependence on Medicaid is associated with admission to lower-quality facilities and to facilities with lower staffing ratios, more regulatory deficiencies, and a higher proportion of residents of color. Eligibility rules also differ across sites of care and across states, even within Medicaid, which may lead to inequities across states.
A second implication of this unsystematic financing approach is the occurrence of site-specific payment, which often creates irrational payment and eligibility differentials which can lead to unintended consequences.
Separate financing and payment systems for home- and community-based care and institutional care create a false dichotomy and present barriers to the rational allocation of resources across settings that considers costs as well as individuals’ needs and preferences.
Previous attempts to develop more cohesive approaches to long-term care coverage have not been successful. As of the writing of this report, the U.S. Congress is considering The Well-Being Insurance for Seniors to be at Home Act, a proposal to use public–private partnerships to provide catastrophic coverage for long-term care. Many other high-income countries have implemented and sustained national long-term care coverage for their populations, incorporating both institutional and home-based care, and the structure of some of these programs could serve as models for the United States.
Improvements in the quality of nursing home care in conjunction with improving access, efficiency, and equity will require a more rational system of financing over the long term. A more rational financing system for nursing home care specifically will likely require a new federal benefit. While the committee acknowledges that enacting a new long-term care benefit will be politically challenging, there is an urgent need for a new, more comprehensive approach to long-term care financing. A federal benefit has the most potential to
- Increase access to long-term care services and reduce unmet need;
- Reduce arbitrary barriers between sites of care;
- Reduce inequities in access to high-quality care;
- Reduce differences in resources across nursing homes; and
- Guarantee that payment rates are adequate to cover the expected level of quality.
Building on lessons learned from experience of the establishment of Medicare Part D as well as the repeal of the Community Living Assistance Services and Support Act, the new benefit would likely require taxpayer subsidies in conjunction with beneficiary premiums and cost sharing. Therefore, the committee recommends the following:
RECOMMENDATION 4A:5 To move toward the establishment of a federal long-term care benefit that would expand access and advance equity for all adults who need long-term care, including nursing home care,
- The Secretary of HHS should study ways in which this federal benefit would be designed to avoid challenges faced by previous efforts to expand long-term care coverage.
- CMS should implement state demonstration programs to test this federal benefit model prior to national implementation.
5 One committee member declined to endorse this recommendation.
Ensuring Adequacy of Medicaid Payments
Medicaid, the federal–state program, is the dominant payer of long-stay nursing home services. Nursing homes depend on higher payments from Medicare to cross-subsidize lower Medicaid payments. This financial arrangement is inefficient for several reasons. First, many nursing homes care for a higher number of Medicaid than Medicare recipients and receive relatively little benefit from higher payments for Medicare services. Research generally finds that nursing homes with a large share of Medicaid residents provide lower-quality care. Increasing Medicaid payment rates to ensure that they are adequate to cover the cost of providing comprehensive, high-quality care to all nursing home residents will be a critical step to addressing existing disparities. Second, the subsidization from Medicare might serve as a disincentive to states to increase their Medicaid reimbursement rates. Finally, lower Medicaid rates encourage nursing homes to prefer short-stay patients covered by Medicare to long-stay nursing home residents covered by Medicaid, resulting in selective admission practices. Lower Medicaid rates relative to Medicare rates encourage the unnecessary hospitalization of long-stay residents in order to have their post-acute care paid for by Medicare upon their return to the nursing home. For these reasons, Medicaid reimbursement rates need to be commensurate with the costs of providing comprehensive, high-quality care for nursing home residents.
Existing law requires state Medicaid programs’ payments to be adequate to provide access to quality care. States are required to provide assurances that their payment rates meet this criterion. For certain providers, CMS requires that states also submit evidence that their payment rates are indeed adequate. Nursing home payment rates are not subject to this requirement, despite Medicaid’s significant role as a payer of nursing home care. CMS needs to fulfill its responsibility as enshrined in existing statute to ensure the adequacy of Medicaid payment rates by requiring nursing homes to provide detailed and accurate financial information (e.g., data on costs, payment levels, resident characteristics, ownership, and corporate structure) upon which the adequacy of rates may be determined. Therefore, the committee recommends the following:
RECOMMENDATION 4B: To ensure that adequate funds are invested in providing comprehensive care for long-stay nursing home residents,
- CMS should ensure compliance with existing statute by using detailed and accurate nursing home financial information to ensure that Medicaid (or eventually, federal) payments are at a level that is adequate to cover the delivery of comprehensive, high-quality, and equitable care by all providers to nursing home residents across all domains of care (as specified in Box 10-1).
Paying for Direct Care Services
An extensive body of research indicates that there is a strong connection between spending on direct care for residents and the quality of that care. The Patient Protection and Affordable Care Act required CMS to develop new Medicare cost reports to capture specific information on nursing home costs in four categories: direct and indirect care, housekeeping and dietary services, capital expenses, and administrative services. However, beyond the reporting requirements, nursing homes are not required by law to devote a specific portion of their payment to direct care for residents. This results in great variability among nursing homes in terms of the actual dollar amount devoted to direct care as opposed to non-care costs. For example, recent evidence has shown a systematic shift in nursing home operating costs toward items such as monitoring fees, interest payments, and lease payments that are associated with the acquisition of nursing homes by private equity owners. Implementing policies that require nursing homes to spend a minimum amount of their revenue on direct resident care and staffing will guard against these types of behaviors. Therefore, the committee recommends the following:
RECOMMENDATION 4C: HHS should require a specific percentage of nursing home Medicare and Medicaid payments to be designated to pay for direct-care services for nursing home residents, including staffing (including both the number of staff and their wages and benefits), behavioral health, and clinical care.
Value-Based Payment for Nursing Homes
Nursing homes are among the most common sites of post-acute care; according to the Medicare Payment Advisory Commission, for example, 20 percent of hospitalized Medicare beneficiaries were discharged to a nursing home for post-acute care in 2018. To control rising post-acute care costs, Medicare joined the prevailing trend toward creating a stronger linkage of payment to the value and quality of care rather than to the quantity of services. Medicare’s entry into the world of value-based payment included the implementation of alternative payment models (APMs) such as accountable care organizations and bundled payments that hold care providers accountable for total costs of care.
Medicare bundled payment demonstrations have found evidence of declining use of nursing home–based acute care without adverse consequences on patient outcomes. Medicare Advantage plans, for their part, have demonstrated a lower use of nursing homes for post-acute care and shorter lengths of stay for common conditions among Medicare Advantage beneficiaries compared with those covered by traditional Medicare.
Given the importance of controlling costs for post-acute care provided in nursing homes, while maintaining or improving quality of care for patients, Medicare needs to build on the experience of existing value-based payment demonstrations. In contrast to the current bundled payments made to nursing homes for a limited number of conditions, however, such arrangements need to be extended to cover the costs of care for all conditions, including acute care in the hospital and post-acute care in the nursing home setting. Bundled payments will shift financial accountability, and thus risk, for nursing home post-acute care to hospitals. In addition, hospitals and other clinicians providing care during an episode of care need to work collaboratively to provide high-quality, equitable, person-centered care and be held financially accountable to this standard by linking payment to quality metrics, including patient-reported outcomes. Indeed, the committee recognizes that there is always a risk of unintended consequences with any new payment model. As bundled payments are expanded to all conditions, close monitoring and rigorous study of the impact on patient outcomes will be required to mitigate any potential unintended consequences. Therefore, the committee recommends the following:
RECOMMENDATION 4D: To improve the value of, and accountability for, Medicare payments for short-stay post-acute care in nursing homes, HHS, CMS, and the Center for Medicare and Medicaid Innovation should extend bundled payment initiatives to all conditions and, in so doing, hold hospitals financially accountable (i.e., put hospitals “at risk”) for Medicare post-acute care spending and outcomes.
The committee also recognizes the importance of the use of value-based payment for long-stay nursing home care. Medicare Advantage institutional special needs plan demonstrations for long-term care in nursing homes have indicated that such arrangements have an impact on critical outcomes such as lower rates of hospitalizations. As with short-stay residents, CMS needs to build on this experience by continuing to test out the use of APMs for long-term nursing home care.
The recommended APMs for long-term care would be separate and distinct from the recommended bundled payment initiatives for short-stay post-acute care. APMs for long-stay nursing home care would rely on global capitated budgets from a single payer and would hold health care provider organizations and health plans financially accountable for the total costs of long-term care in nursing homes. The global capitated rate would cover post-acute care, long-term care, and hospice care. Grouping the entire range of services into one global rate enhances care coordination and improves the management of the overall cost of care. In recommending these APMs as demonstration projects, the committee recognizes that the impact
of APMs for long-stay nursing home care is unknown, but it concludes that the evidence to date warrants further exploration and testing of APMs in real-world situations.
Moreover, the committee is aware that there is not yet strong evidence that the use of value-based payments can improve access to care or health outcomes for vulnerable populations (e.g., racial and ethnic minorities, rural populations, and individuals with disabilities). While CMS has devoted attention to monitoring the unintended impact of value-based payment on at-risk populations, it is important to consider that the tenacious inequities and disparities within the health care system are indicative of a more extensive systemic bias—both societal and at the level of the broader health care system. If value-based payment is to serve as an alternative payment model designed to increase value and enhance equity, it must be capable of influencing the issues that directly affect access to and the quality of health care services.
Equally important is that a targeted focus on reducing health disparities needs to be an explicit part of using APMs to pay for nursing home care. The quality measurement and quality goals that APMs use to determine payment need to include measures of improving outcomes for disadvantaged populations and reducing existing disparities. All new programs also need to include explicit monitoring and evaluation of health care disparities.
The biggest challenge for achieving health equity under APMs is related to the disparate financial resources across different providers of care. It is important to note that addressing payment inequities across nursing homes by increasing Medicaid payment rates to levels adequate to cover the costs of providing comprehensive care for such residents, as discussed above, will be an essential step to avoid further exacerbating disparities. Therefore, the committee recommends the following:
RECOMMENDATION 4E: To eliminate the current financial misalignment for long-stay residents introduced by Medicaid’s coverage of their nursing home services and Medicare’s coverage of health care services, HHS and CMS should conduct demonstration projects to explore the use of APMs for long-term nursing home care, separate from bundled payment initiatives for post-acute care. These APMs would use global capitated budgets, making care provider organizations or health plans accountable for the total costs of care.
- APM’s capitated rate should include post-acute care and hospice care for long-term nursing home residents to address financial misalignment between Medicare and Medicaid payments, while supporting care coordination.
- Designs and payments of the demonstration projects should be tied to broad-based quality metrics, including staffing metrics, residents’ experience of care, functional status, and end-of-life care to ensure that APMs maintain quality of care, particularly in areas such as post-acute care, end-of-life care, and hospice care.
The federal government’s formal involvement with the oversight of nursing homes essentially started with the enactment of Medicare and Medicaid in 1965 and the related requirements of participation for nursing homes. Over the decades, various laws and federal regulations sought to improve the quality of care in nursing homes and also improve the oversight and regulation of nursing homes’ performance (see Chapter 8, Box 8-1). Nursing home quality assurance activities are largely defined by the statutory requirements of OBRA 87 and associated regulations put forward by CMS. However, substantial changes have occurred in nursing home care since the implementation of OBRA 87, but the general structure of the oversight and regulation of nursing homes has largely remained the same.
State Surveys and CMS Oversight
States assist with the assessment of facilities’ compliance with requirements of participation through regular inspections (roughly once a year) and, as necessary, the investigation of complaints and adverse incidents. Although federal oversight standards and processes are uniform across states, considerable variation in processes and outcomes exists in the implementation of routine inspection responsibilities, in the imposition of sanctions, and in the investigation of complaints. Multiple organizations have called for the strengthening of surveyor qualifications, and several reports note the challenges in hiring qualified surveyor staff, but there is very little literature evaluating surveyors’ qualifications or the effectiveness of their training. Moreover, several reports from the GAO and U.S. Office of the Inspector General (OIG) over the past two decades have found failures in the survey process to properly identify serious care problems, fully correct and prevent recurrence of identified problems, and investigate complaints in a timely manner. For example, ten states did not meet performance thresholds for timeliness in addressing high-priority complaints for eight consecutive years (2011–2018). And while CMS is able to impose remedies or sanctions if a state is found to have performed inadequately, in January 2022, the OIG found that CMS often did not fully track these remedies and they rarely imposed formal sanctions.
The committee concluded that state survey agencies may not have adequate capacity (including the number of trained surveyors) or resources to fulfill all their responsibilities. The committee additionally concluded that CMS does not provide sufficient oversight of or transparency in the state survey process, and they do not adequately enforce existing sanctions for failures in performance of the states’ duties. Therefore, the committee recommends the following:
RECOMMENDATION 5A: CMS should ensure that state survey agencies have adequate capacity, organizational structure, and resources to fulfill their current nursing home oversight responsibilities for monitoring, investigation, and enforcement.
- In particular, CMS should ensure that state survey agencies have adequate capacity and resources to deliver a strong, consistent, responsive, and transparent process for complaints.
- Along with providing the necessary resources, CMS should refine and expand oversight performance metrics of survey agencies for annual public reporting which would facilitate greater accountability related to whether existing federal regulations are being consistently and completely enforced and would highlight shortcomings that need to be addressed.
- CMS should use existing strategies of enforcement where states have consistently fallen short of expected standards.
The committee notes that these resources need to be available for a variety of purposes, including increasing the number of survey staff, improvements in surveyor training, and enhanced compensation.
The current quality assurance process is largely a standardized enterprise, with almost all facilities inspected at the same frequency for compliance with the same standards on a roughly annual basis. Additionally, even with a range of enforcement options available, civil monetary penalties have been by far the most common remedy used in recent years to sanction nursing homes. However, the level and extent of use of these penalties may not be sufficient to effect desired changes. Furthermore, the budget of the Special Focus Facility program, a program that targets more frequent inspections and quality improvement activities to the lowest-performing facilities, only allows for oversight of a very small fraction of such nursing homes, and many participants who complete the program fail to sustain improvement.
Despite the prominent role of nursing home oversight and regulation, the evidence base for its effectiveness in ensuring a minimum standard of quality is relatively modest. Most resident advocates and nursing home providers have expressed dissatisfaction with the effectiveness of the current
nursing home regulatory model, and a variety of new approaches have been suggested, yet little consensus (or evidence) exists on how exactly to improve quality assurance efforts, including the survey process. Nursing home advocates highlight the fact that, as noted earlier, existing regulations are often not being completely and consistently enforced and suggest that additional regulations need to be put in place to fully protect residents. Alternatively, many providers believe that the existing regulations are excessive and impede innovation and good-quality care. The committee concluded that while the current regulatory process needs significant improvement, particularly in relation to the uneven enforcement of regulations, there is a dearth of evidence to suggest which approaches would ultimately lead to improvement in the quality of care for nursing home residents. In order to determine the optimal use of existing and expanded resources and make the quality assurance processes more efficient and effective, the committee recommends the following:
RECOMMENDATION 5B: CMS should develop and evaluate strategies (including the evaluation of potential unintended consequences) that make nursing home quality assurance efforts more effective, efficient, and responsive, including potential longer-term reforms such as
- Enhanced data monitoring (using prior survey performance in combination with real-time quality metrics) to track performance and triage onsite inspections of facilities;
- Increased oversight across a broader segment of poorly performing facilities (e.g., through substantially improving the Special Focus Facilities program);
Modified formal oversight activities for high-performing facilities, including the consideration of more targeted inspections, provided adequate safeguards are in place, including
- Surveyors present on site at least annually,
- States meeting expected standards for responding to complaints, and
- Nursing homes continuing to meet specified, real-time quality metrics (e.g., a robust threshold of staffing hours per resident day, stable ownership); and
- Greater use of enforcement remedies beyond civil monetary penalties, including chain-wide corporate integrity agreements, denial of admissions, directed plans of correction, temporary management, and termination from Medicare and Medicaid.
The committee notes that concerns have been raised as to whether oversight can be reduced in some manner (e.g., less frequent surveys, less intense
surveys) for high performers. In particular, the concern is that significant safety risks or markers of decreases in quality (e.g., significant changes in staffing patterns) might occur in the interim between surveys. Therefore, the committee emphasizes the importance of using real-time quality metrics as an “early warning system” in conjunction with testing these approaches to ensure that safety and overall quality can be monitored and that intervention can occur quickly if problems arise.
The Long-Term Care Ombudsman Program
The Long-Term Care Ombudsman Program is the only entity within the nursing home system whose sole mission is to be an advocate for the residents to ensure that they receive the care to which they are entitled. The impact of the program has been largely positive, especially given the modest investment of governmental resources. However, there is considerable variation in the amount of resources, funding, and staffing among the various state programs. The committee concluded that limited funding affects many programs’ abilities to meet federal and state requirements and fully provide nursing home residents and their families with the best support possible. Therefore, the committee recommends the following:
RECOMMENDATION 5C: The Administration for Community Living should advocate for increased funding for the Long-Term Care Ombudsman Program. Additional resources should be allocated toward
- Hiring additional paid staff and training staff and volunteers,
- Bolstering programmatic infrastructure (e.g., electronic data monitoring systems to track staff and volunteer activities and track resident and family complaints),
- Making data on state long-term care ombudsman programs and activities publicly available, and
- Developing summary metrics designed to document the effectiveness of the Long-Term Care Ombudsman Program in advocating for nursing home residents.
Additionally, states should contribute funds to their long-term care ombudsman programs to address cross-state variation in the extent to which these programs have the capacity to advocate for nursing home residents. Along with additional resources, all State Units on Aging should develop plans for their long-term care ombudsman programs to interface effectively with collaborating entities such as adult protective services, state survey agencies, and state and local law enforcement agencies.
Quality Assurance, Transparency, and Accountability
As noted earlier, the committee concluded that increased transparency and accountability will help improve the quality of care in nursing homes. The committee recommended that HHS should collect, audit, and make publicly available detailed facility-level data on the finances, operations, and ownership of all nursing homes (Recommendation 3A), and that these data are made available in a real-time, readily usable, and searchable database that allows for evaluation and track the quality of care for facilities with common ownership or management company (Recommendation 3B). Accurate and complete data will enable regulators to identify poor quality of care by owner or management company and levy sanctions as appropriate. Therefore, the committee recommends the following:
RECOMMENDATION 5D: When data on the finances and ownership of nursing homes reveal a pattern of poor-quality care across facilities with a common owner (including across states), federal and state oversight agencies (e.g., CMS, state licensure and survey agencies, the Department of Justice) should impose oversight and enforcement actions on the owner. These actions may include
- Denial of new or renewed licensure,
- The imposition of sanctions, including the exclusion of individuals and entities from participation in Medicare and Medicaid, and
- The implementation of strengthened oversight (e.g., through an improved and expanded special focus facilities program).
Certificate-of-Need Regulations and Construction Moratoria
As part of quality assurance, some states maintain certificate-of-need requirements to regulate expansions in the health care market, purportedly as a strategy to constrain health care spending. Certificate-of-need policies employ a need-based evaluation of all applications for new construction or additions to existing facilities that would increase the number of beds. Additionally, some states have implemented construction moratoria that prohibit the building of new health care facilities. For health care markets in general, certificate-of-need regulations have been found to be largely ineffective.
The logic behind certificate-of-need regulations for nursing homes specifically is that limiting the number of beds will, in turn, limit the number of Medicaid beneficiaries in nursing home settings, thus keeping state Medicaid spending to a lower level. However, the evidence does not suggest that these policies have much impact on overall Medicaid nursing home spending. On the other hand, nursing home certificate-of-need regulations have been
found to limit choice and lower access to medical services and health care resources, especially for those in rural areas; decrease the quality of care for some measures of quality; and increase private-pay prices. Certificate-of-need regulations and construction moratoria can also discourage innovation by preventing the entry of more modern nursing home options (such as those that embrace principles of culture change) and restricting facility renovation and remodeling. As a result, these policies may contribute to the perpetuation of larger nursing homes, rather than the smaller, more home-like settings that are more desirable. There is no evidence that lifting certificate-of-need regulations will increase Medicaid spending on institutional care or reduce investment in home- and community-based settings of long-term care.
The committee concludes that while certificate-of-need regulations do not appear to have their intended effect of holding down Medicaid nursing home spending, they can have the unintended effect of harming consumers by limiting choice and access. Therefore, the committee recommends the following:
RECOMMENDATION 5E: States should eliminate certificate-of-need requirements and construction moratoria for nursing homes to encourage the entry of innovative care models and foster robust competition in order to expand consumer choice and improve quality.
The committee emphasizes that the elimination of such restrictive policies is not intended as a mechanism to increase the use of nursing homes or to invest in nursing homes in lieu of other long-term settings of care. Rather, the committee seeks to expand consumer choice for those who need and choose nursing home care by encouraging competition on the basis of quality.
The primary purpose of quality measurement is to improve the quality of care and outcomes. Effective quality measures can be used for continuous quality improvement activities.
The CMS website Care Compare provides public reporting of quality measures for nursing homes. However, it does not directly report on a key domain of high-quality care—resident and family satisfaction and experience. Technical measures of care processes and outcomes are only moderately correlated with resident and family reports of the quality of the experience of care. Furthermore, obtaining residents’ and families’
assessment of their care experience becomes even more important in the nursing home setting, where residents have high levels of support needs and rely on the nursing home staff and environment to meet their needs on a continuing basis for weeks, months, or even years.
While many nursing home administrators report using resident and family satisfaction surveys, and satisfaction information is reported as being useful, the surveys being used vary widely and may not be adequately validated. CMS mandates the collection of Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys in several settings or populations (e.g., hospitals, Medicare Advantage, home health care, hospice care) by independent, credentialed survey vendors, and AHRQ supports the ongoing evaluation of item performance and the association of ratings with patient characteristics. Nursing home CAHPS measures had extensive item development and testing for reliability and validity. However, the collection of the nursing home CAHPS survey is not required.
The committee concluded that the lack of inclusion of measures of resident and family satisfaction and experience in Care Compare impedes the ability of individuals and their families to make fully informed choices about providers and facilities. It also disadvantages nursing homes, which cannot benefit from using consumer reports of their experiences to improve services and care delivery. Therefore, the committee recommends the following:
RECOMMENDATION 6A: CMS should add the CAHPS measures of resident and family experience (i.e., the nursing home CAHPS surveys) to Care Compare.
- Data for this measure should be collected annually by independent reviewers (i.e., not nursing home staff) in all nursing homes.
- As data are collected nationally, ongoing psychometric testing should occur to refine the measures in order to support submission for endorsement by the National Quality Forum.
The committee supports the use of the nursing home CAHPS measures given that they are by far the most well-validated measures of resident and family experience. The committee recognizes that the cost, administration, and analysis of the CAHPS nursing home survey will be expensive and present logistical challenges. However, as noted above, the committee concluded that failure to capture the voices of residents and their families in quality measurement neglects a crucial aspect of quality. The committee emphasizes that the use of these measures is not intended to replace the crucial roles of the formal complaints process or hearing from resident and family councils, as measures of resident and family satisfaction capture a different and
very important aspect of the resident and family experience. Rather, all of these mechanisms provide important insights. Finally, the committee supports consideration for eventually integrating the CAHPS measure into the five-star rating, and recognizes that continued research on what matters to residents and their families is needed to refine quality measurement efforts.
In addition to adding measures that reflect the resident and family experience, the committee concluded that Care Compare needs to be enhanced and expanded through the inclusion of more measures that can help to more fully reflect the quality of care in nursing homes. Many of these measures can be readily reported from data already collected by CMS. As noted earlier, increasing the transparency of nursing home ownership should include the ability to track quality of care by common owner or management company. Finally, the current five-star rating system is unable to distinguish modest increments in the quality of care among nursing homes with average ratings, and more work is needed to improve the validity of existing measures, such as by auditing reported data for accuracy. Therefore, the committee recommends the following:
RECOMMENDATION 6B: HHS, CMS, NIH, and AHRQ should expand and enhance existing publicly reported quality measures in Care Compare by
- Increasing the weight of staffing measures within the five-star composite rating;
- Facilitating the ability to see quality performance of facilities that share common ownership (i.e., chain and other multifacility owners) or management company;
- Improving the validity of Minimum Data Set–based measures of clinical quality (e.g., better risk adjustment, auditing for accuracy, inclusion of resident preferences); and
- Conducting additional testing to improve the differentiation of the five-star composite rating so that it better distinguishes among the middle ranges of rating, not just at the extremes.
Finally, the committee found that several other key domains of high-quality care are not reflected among the measures in Care Compare and concluded that more work is needed to develop and test valid measures for these domains of care. Therefore, the committee recommends the following:
RECOMMENDATION 6C: HHS should fund the development and adoption of new nursing home measures to Care Compare related to
- Palliative care and end-of-life care;
- Implementation of the resident’s care plan;
- Receipt of care that aligns with resident’s goals and the attainment of those goals;
- Staff well-being and satisfaction;
- Psychosocial and behavioral health; and
- Structural measures (e.g., health information technology adoption and interoperability; the percentage of single occupancy rooms; emergency preparedness, routine training in infection prevention; emergency response management; financial performance; staff employment arrangements [e.g., full-time, part-time, contract, and agency staff]).
The areas recommended are important for consumers to consider when seeking nursing home care that best meets their needs and for nursing homes to use in improving their care and services.
The quality of nursing home care is particularly concerning for several high-risk populations who experience significant disparities in care, including racial and ethnic minorities and LGBTQ+ populations. For example, nursing homes in low-income neighborhoods with high numbers of minority residents have lower quality-of-care ratings. Additionally, the COVID-19 pandemic initially had a greater impact on nursing homes that serve disproportionately more non-White residents. However, the lack of robust data specific to race and ethnicity in nursing homes makes it difficult to document the true extent and impact of disparities in care. The committee concluded that while developing measures of disparities in nursing home care is needed, doing so needs to be based on an overall health equity strategy for nursing homes. Therefore, the committee recommends the following:
RECOMMENDATION 6D: HHS should develop an overall health equity strategy for nursing homes that includes defining, measuring, evaluating, and intervening on disparities in nursing home care. The strategy should include
- Definitions of health equity and disparities in nursing homes, including disparities related to race, ethnicity, LGBTQ+ populations, and sources of payment;
- The development of new measures of disparities in nursing home care, both within and across facilities, at the national, state, and ownership levels, to be included in a national report card.
As a first step, a minimum data set of information to identify and describe disparities should be established, with data collected at least annually and
made publicly available. The information should include characteristics of the communities in which nursing homes are embedded as well as the ability of community members to access nursing home care.
- Research regarding disparities and the development of policies and culturally tailored interventions should be a priority for funding by HHS, NIH, and other sources.
- HHS, in partnership with state and local governments, should use data to identify the types and degree of disparity to prioritize when action is needed and to identify the promising pathways to reduce or eliminate those disparities.
Standardized, required CMS quality measures have guided quality improvement efforts. In 2016, the ACA required that all skilled nursing facilities implement quality assurance and performance-improvement programs as a requirement of participation for reimbursement by Medicare and Medicaid. The extent to which individual facilities engage in quality improvement and the effectiveness of such activities is unknown. Furthermore, many facilities lack adequate expertise and resources for effective quality improvement. Technical assistance is one of the primary mechanisms of quality improvement. The role of technical assistance depends in part upon the nursing home recognizing its need for additional knowledge and expertise. Without a motive to improve quality, little change may occur.
The committee recognizes the role of CMS’s quality improvement organization (QIO) program in providing technical assistance on a variety of topics to improve the quality of health care in general. However, the focus of the QIO program varies by scope of work, and attention to nursing homes specifically has been inconsistent. Furthermore, the evidence base about the effectiveness and relative contribution of QIOs to quality improvement in health care, and particularly for nursing homes, is lacking. On the other hand, evidence suggests that state-based programs that focus on helping nursing home staff with quality improvement activities within nursing homes using onsite assistance by expert clinical staff and collaborating groups are effective in improving quality of care and that their help is widely accepted by nursing homes. State and local programs may be particularly well suited to provide technical assistance due to familiarity with the circumstances of the local community, the ability to be seen as a trusted peer, and the development of specific expertise due to a continued solitary focus on nursing home quality. For example, state and local technical assistance programs have been effective at building trusting relationships, modifying technical assistance approaches to meet local needs
and skills, and keeping up to date with scientific content. Such programs may also help integrate nursing homes into their local communities as well as the broader health care system.
The committee concluded that nursing homes would benefit from the availability of technical assistance from individuals at the state (or even local) level who are most familiar with their specific communities and challenges, have specific expertise in nursing home quality, and have a consistent and ongoing focus on nursing homes. Therefore, the committee recommends the following:
RECOMMENDATION 6E: CMS should allocate funds to state governments for grants to develop and operate state-based, nonprofit, confidential technical assistance programs that have an ongoing and consistent focus on nursing homes. These programs should provide up-to-date, evidence-based education and guidance in best clinical and operational practices to help nursing homes implement effective continuous quality-improvement activities to improve care and nursing home operations.
- CMS should create explicit standards for these programs to promote comparable programs across states.
- The program should conduct ongoing analysis and reporting of effectiveness of the services provided.
- The program should provide services to all nursing homes in the state, with a focus on those identified as being at risk for poor performance, but also available to those with moderate and high performance.
- The program should coordinate with state surveyors and ombudsmen and receive referrals regarding facilities needing assistance, but maintain the confidentiality of the details of the services provided to each facility (notwithstanding the mandated reporting requirements in each state regarding resident abuse and neglect).
- The programs should consider partnering with relevant academic institutions of higher education, such as colleges of nursing, medicine, social work, rehabilitation services, and others.
Research increasingly demonstrates the key role of HIT in health care settings, given its potential contribution to a range of outcomes, including increasing efficiency in care delivery, enhancing care coordination, improving staff productivity, promoting patient safety, and improving quality of care. The COVID-19 pandemic underscored the critical importance of HIT
applications, such as videoconferencing and telehealth, providing vitally important means of connectivity and communication when nursing home lockdowns instituted to protect vulnerable residents from infection led to limited access to in-person clinical visits as well as residents’ isolation from friends and family members.
HIT includes technologies such as electronic health records (EHRs), which have a wide range of uses, including real-time data sharing capabilities, digital prescriptions, automated medication dispensing, clinical decision-support services, and support functions related to billing, reimbursement, and administrative tasks. Members of the interdisciplinary care team would benefit from application of EHRs’ multiple functions to improve the quality of care for nursing home residents.
In contrast to hospitals and acute-care settings, however, the long-term care sector—and nursing homes in particular—has been slower to adopt EHRs. Nursing home residents often have complex medical conditions that require care coordination among hospitals and other care settings, further underscoring the need for nursing homes to have EHRs that communicate with other systems in order to ensure smooth and safe care transitions as patients move from one health care setting to another.
Eligible hospitals and health care providers have long benefited from financial incentives to support EHR adoption, which were initially contained in the EHR Incentive Program created by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, recently revised and renamed the CMS Promoting Interoperability Program. Nursing homes were not included among those hospitals and health care professionals eligible to participate in the incentive program, and thus they have not benefited from the program’s financial incentives, which sunset in 2021.
Cost is a significant barrier to EHR adoption by nursing homes, and absent the federal incentives provided to other health care providers, the prevalence, quality, and comprehensiveness of EHR adoption in nursing homes is well below that in other health care settings. Given the benefits of EHRs for both residents and staff, the committee recommends the following:
RECOMMENDATION 7A: The Office of the National Coordinator (ONC) and CMS should identify a pathway to provide financial incentives to nursing homes for certified EHR adoption that supports health information exchanges to enhance person-centered longitudinal care. These incentives should be modeled on the HITECH incentives provided to eligible hospitals and professionals.
- ONC should ensure that the nursing home program complements the Promoting Interoperability Program; and
- ONC should develop appropriate nursing home EHR certification criteria that promote adoption of health information exchange of important clinical data (e.g., admission, discharge, and transfer data).
Ideally, the collection and recording of patient data and information would occur as close to the provision of patient care (i.e., at the bedside) as possible. Such real-time data entry has been shown to improve patient care, allowing for quicker results of laboratory tests and medication orders and providing more decision-making support to the clinicians. Moreover, capturing patient data in real time benefits patients who receive improved care, which leads to greater patient satisfaction. Finally, real-time data entry can reduce duplication of documentation and, in so doing, contribute to the overall efficiency of nursing home staff.
As more and more nursing homes adopt HIT, it is critical to monitor and track HIT adoption and interoperability (i.e., the ability to communicate with other EHRs). In order to comply with Merit-Based Incentive Payment System requirements, nursing homes should be expected to use HIT in resident care delivery. However, HIT adoption varies from nursing home to nursing home, with some nursing homes using complete EHRs, while others may have partial EHR capabilities. Given this variability, a baseline measure of HIT adoption needs to be developed. One option would be to measure nursing home use of real-time HIT approaches for resident care delivery. As nursing homes use new measures to assess HIT adoption and interoperability, the results need to be publicly reported in Care Compare.
In addition, the usability of HIT, which encompasses effectiveness, efficiency, and satisfaction, needs to be assessed. This is critically important because if a HIT system is not easy to use or is perceived as making more work for nursing home staff rather than decreasing their workload, then it will not be used to its full potential. It is vital to understand the various barriers and facilitators to HIT use in nursing homes and to use the results of the assessments to improve the efficiency, effectiveness of, and satisfaction with HIT—on the part of nursing home staff as well as residents and families. Therefore, the committee recommends the following:
RECOMMENDATION 7B: In order to measure and report on HIT adoption and interoperability in nursing homes, HHS should
- Develop measures for HIT adoption and interoperability, consistent with other health care organizations;
- Measure levels of HIT adoption and interoperability on an annual basis and report results in Care Compare; and
- Measure and report nursing home staff, resident, and family perceptions of HIT usability.
The ability of HIT to realize its potential to improve safety and quality of care and to increase staff productivity is contingent upon several key factors, including the training of nursing home leadership and staff. Despite research that demonstrates that training is a key contributor to staff satisfaction with HIT, most nursing homes do not provide adequate training for staff in the optimal use of HIT. Given the key role of training, the federal government should provide incentives for the training of nursing home leadership and staff members in agreed-upon HIT core competency areas. Therefore, the committee recommends the following:
RECOMMENDATION 7C: CMS and HRSA should provide financial support for the development and ongoing implementation of workforce training, emphasizing core HIT competencies for nursing home leadership and staff, such as clinical decision support, telehealth, integration of clinical processes, interoperability, and knowledge management in patient care.
In order to create an environment of continuous learning and quality improvement, evaluation studies need to be conducted to assess the impact of HIT on resident outcome, and to examine innovative ways to use HIT to improve resident care. Studies will help nursing homes understand the key challenges of HIT adoption and use by exploring the perceptions of clinicians as well as residents of HIT usability. Moreover, studies also need to explore the disparities in HIT adoption and use across nursing homes, paying particular attention to differences in geographic location (rural versus urban), ownership status, the size of the nursing home, and specific patient populations served by individual nursing homes. Therefore, the committee recommends the following:
RECOMMENDATION 7D: ONC and AHRQ should fund rigorous evaluation studies to explore
- The use of HIT to improve nursing home resident outcomes;
- Disparities in HIT adoption and use across nursing homes;
- Innovative HIT applications for resident care; and
- The assessment of clinician, resident, and family perceptions of HIT usability
As discussed at the beginning of this report, the committee’s conceptual model presents a vision for high-quality care in nursing homes, and the committee’s goals and recommendations identify specific steps to achieve this vision of improving nursing home care. It is important to consider the
impact of the committee’s recommendations from the perspective of nursing home residents, families, and staff.
First and foremost, the resident and his or her chosen family would take center stage, according to the tenets of person-centered care to maintain the resident’s dignity, maximize independence, balance autonomy and safety, and enable meaningful relationships. Quality nursing home care would be provided to all residents, both short-stay and long-stay, and respond to the substantial differences in their care needs, goals, and preferences.
Overall, the goals, values, and preferences of the individual would be known and met, and nursing home residents would experience the best possible quality of life—thriving rather than merely surviving. Residents would have independence (as appropriate), and they would have the ability to participate in meaningful and person-centered activities that meet their potential and result in a sense of self-worth. Younger residents would have access to age-appropriate activities and environments, freedom and expression, and opportunities to interact with peers. Residents and their families would experience high satisfaction with the care they are receiving, and their voices would be heard and fully integrated into processes of quality measurement, quality improvement, and quality assurance.
Every nursing home resident would receive appropriate and effective care in a timely manner. This care would be both individualized and comprehensive, including care to support basic daily needs (e.g., hydration, nutrition, and elimination), assessment, acute care needs, chronic disease management, behavioral and social care, spiritual care, the preservation of function (e.g., cognitive and physical) and comfort, palliative care, and end-of-life care. Care coordination would include seamless transitions to other settings of care (as needed), and all nursing homes would have state-of-the-art health information systems to facilitate the sharing of information across care settings.
Individuals working in nursing homes would be highly trained and appropriately compensated, and a stable nursing home leadership would help create a supportive work environment. There would be adequate numbers of staff with high job satisfaction and low turnover rates, which would enable residents to receive consistent care from an interdisciplinary team that knows them well as a person and is able to help meet their individual goals. Staff would be compassionate and have adequate time to spend with residents for iterative care planning and decision making related to their personalized goals of care as well as time to engage socially with the resident. Staff members would have the knowledge, skills, and tools to competently and confidently carry out their work, including the ability to recognize and respond to subtle changes in residents’ needs, and the entire range of nursing home workers would be respected and supported by their supervisors and engaged in team-based decision making. They would be
well trained in the effective use of health information technology such as electronic health records to enhance their productivity as well as improve the quality of care provided to residents. In short, nursing homes will be places where people want to work and advance their professional careers.
In addition to being places where people want to work, nursing homes will be places where people want to live. To do so, nursing homes will be redesigned and reconfigured to actually resemble home-like settings rather than medical institutions. Single-occupancy bedrooms with private bathrooms will be the standard, and nursing homes will provide a variety of activities to engage residents while ensuring residents have the opportunity to the visit with friends and family when they want. The social environment would include connections to the local community. The physical environment of the nursing home would be clean and odor free, have good lighting, and be characterized as a calm, safe, and secure environment (e.g., free of injury, abuse, theft, and acquired infections). Such features as single-occupancy rooms and private bathrooms as well as the provision of a clean, safe, and secure environment is provided for short-stay nursing home residents as well.
The financing of nursing home care would ensure adequate funding for high-quality care, including assistance with activities of daily living, behavioral health and psychosocial care, oral health, hearing and vision, and end-of-life care. Payment models for care would more closely link payment to value rather than to the volume of services provided and, in so doing, would discourage wasteful spending. No resident or family would be faced with the prospect of spending down all their assets in order to receive nursing home care. Information on the operations of the nursing home, including the ownership structure, involvement of third parties, and spending patterns would be completely transparent to residents, families, researchers, and those responsible for nursing home regulatory oversight and quality assurance.
Nursing home oversight would be carried out by surveyors who are well trained and dedicated to their work. Deficiencies in nursing homes would be identified and resolved quickly and consistently. Nursing home residents and their families would be unafraid to voice their grievances and concerns, which would be acknowledged and swiftly addressed through an efficient and transparent grievances process and a robust Long-Term Care Ombudsman Program. Nursing home owners and management companies with severe citations within and across facilities would be sanctioned appropriately; if severe violations are noted repeatedly or go unresolved, nursing homes would be terminated from participation in Medicare and Medicaid. Nursing homes would be able to receive technical assistance as desired to address quality concerns. In short, nursing home owners will be held accountable for the care provided in their facilities.
Finally, nursing home residents and their families would have access to critical information to help them choose a high-quality nursing home that is best able to meet their goals, values, and preferences. Additionally, residents, families, and other stakeholders (e.g., states, researchers) would have access to information about the finances, operation, and ownership of nursing homes and be able to understand the quality of care provided across common ownership or management.
The urgency to reform how care is financed, delivered, and regulated in nursing home settings is undeniable. Failure to act will guarantee the continuation of many shortcomings that prevent the delivery of high-quality care in all nursing homes. The COVID-19 pandemic provided powerful evidence of the deleterious impact of inaction and inattention to longstanding quality problems on residents, families, and staff. The disruption of the pandemic, however, also serves as a stark reminder that nursing homes need to be better prepared to respond effectively to the next public health emergency, and serves as an impetus to drive critically important and urgently needed innovations to improve the quality of nursing home care. Implementing the committee’s integrated set of recommendations will move the nation closer to making high-quality, person-centered, and equitable care a reality.
It has been 35 years since the passage of OBRA 87 and landmark nursing home reform measures. It is of the utmost importance that all nursing home partners work together to ensure that residents, their chosen families, and staff will no longer have to wait for needed improvements to the quality of care in nursing homes. The time to act is now.
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