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Suggested Citation:"Appendix D: Recommendations by Responsible Partners." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
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Appendix D

Recommendations by Responsible Partners


TABLE D-1 Implementation of the Committee’s Recommendations Organized by Responsible Partners

Responsible Partner Rec
U.S. Congress
All relevant federal agencies need to be granted the authority and resources from the U.S. Congress to implement the recommendations of this report.
Secretary of HHS
Study ways to establish a new federal long-term care benefit that would expand access and advance equity for all adults who need long-term care, including nursing home care. 4A
HHS as the lead agency (includes individual agencies within HHS)
Fund research to identify and rigorously test specific minimum and optimum staffing standards for direct-care staff based on resident case mix, and type of staff needed to address the care needs of specific populations. (HHS, e.g., CMS, AHRQ, NIH) 2C
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. (HRSA) 2E
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). (HHS, e.g., CMS, AHRQ, NIH) 2I
Suggested Citation:"Appendix D: Recommendations by Responsible Partners." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
Collect, audit, and make available detailed facility-level data on the finances, operations, and ownership of all nursing homes, ensuring that data allow assessment of staffing patterns, deficiencies, financial arrangements, and payments, related party entities, corporate structures, and objective quality indicators by common owner and management company are available in a real-time, readily usable, and searchable database. 3A, 3B
Require designation of a specific percentage of nursing home Medicare and Medicaid payments to pay for direct care, including staffing (including both the number of staff and their wages and benefits), behavioral health, and clinical care. 4C
Extend bundled payment initiatives for short-stay nursing home acute care to include all conditions, and hold hospitals financially accountable (i.e., put hospitals “at risk”) for Medicare post-acute care spending and outcomes as part of effort to improve the value of and accountability for Medicare short-stay postacute nursing home payments. (HHS/CMS/CMMI) 4D
Conduct demonstration projects to explore the use of APMs that will eliminate current misalignment for long-stay residents by fragmented payment system. APMs to use global capitated budgets from a single payer, making provider organizations or plans accountable for total costs of care. APM’s capitated rate to 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, resident 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. (HHS/CMS) 4E
Advocate for increased funding for LTC ombudsman programs with additional resources allocated toward hiring additional paid staff and training staff and volunteers, bolstering programmatic infrastructure, making data on state LTC ombudsman programs and activities publicly available, and developing summary metrics designed to document the effectiveness of these programs in advocating for nursing home residents. (ACL) 5C
Expand and enhance existing publicly reported quality measures in Care Compare:
  • Increase the weight of staffing measures within the five-star composite rating
  • Facilitate the ability to see quality performance of facilities that share common ownership
  • Improve validity of MDS-based clinical quality
  • Conduct additional testing to improve differentiation of the five-star composite rating (HHS/CMS/NIH/AHRQ)
6B
Fund the development and adoption of new nursing home measures to Care Compare related to palliative and end-of-life care, receipt of care that aligns with resident’s goals and the attainment of those goals, implementation of the resident’s care plan, staff satisfaction, and psychosocial and behavioral health. Also develop and adopt new structural measures (e.g., HIT adoption and interoperability; single-occupancy rooms; emergency preparedness; infection prevention training; financial performance; staff employment arrangements). 6C
Suggested Citation:"Appendix D: Recommendations by Responsible Partners." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
Develop an overall health equity strategy for nursing homes that includes defining, measuring, evaluating, and intervening on disparities in nursing home care. Specifically, strategy to include definitions of health equity and disparities in nursing homes, including race, ethnicity, LGBTQ+ populations, and sources of payment; new measures of disparities in nursing home care to be included in a national report card. Prioritize funding research regarding disparities and the development of policies and culturally tailored interventions. (HHS, NIH, and other agencies) 6D
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. (HHS, in partnership with state and local governments)
Identify a pathway to provide financial incentives to nursing homes for certified EHR adoption and develop EHR certification criteria that promote adoption of health information exchange. (CMS, ONC) 7A
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; measure and report nursing home staff, resident, and family perceptions of HIT usability. (HHS) 7B
Provide financial support for the development and ongoing implementation of workforce training emphasizing core HIT competencies for nursing home leadership and staff. (CMS, HRSA) 7C
Fund rigorous evaluation studies to explore 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 assessment of clinician, resident, and family perceptions of HIT usability. (ONC, AHRQ) 7D
CMS as lead agency
Enhance the current minimum staffing requirements for every nursing home to include
  1. Minimum on-site RN 24/7 coverage (in addition to the director of nursing) with additional RN coverage that reflects resident census, acuity, and case mix as well as needs as determined by the residents’ assessments and care plans
  2. Full-time social worker with a minimum of bachelor’s degree in social work from a program accredited by CSWE and 1 year of supervised social work experience working directly with individuals to address behavioral and psychosocial care
  3. An infection prevention and control specialist who is an RN, APRN, or a physician at a level of dedicated time sufficient to meet the needs of the size and case mix of the nursing home
2B
Create incentives for nursing homes to hire qualified licensed clinical social workers at the M.S.W. or Ph.D. level and APRNs for clinical care, including allowing Medicare billing and reimbursement for these services. 2D
Suggested Citation:"Appendix D: Recommendations by Responsible Partners." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
Establish minimum education and national competency requirements for nursing home staff, including nursing home administrator, medical director, director of nursing, director of social services, and CNAs. 2F
Require all levels of nursing home staff to complete annual continuing education training to meet national competency standards. 2G
Implement state demonstration programs (prior to national implementation) to test a model for 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. 4A
Ensure Medicaid payments are at a level adequate to cover the delivery of comprehensive, high-quality, and equitable care to nursing home residents across all domains of care as required by existing statute. 4B
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, particularly for complaints. Refine and expand oversight performance metrics for annual public reporting to facilitate greater accountability that existing federal regulations are being consistently and completely enforced. Use existing strategies of enforcement where states have consistently fallen short of expected standards. 5A
Develop and evaluate strategies that make nursing home quality-assurance efforts more efficient, effective, and responsive, including potential longer-term reforms such as
  • Enhanced data monitoring;
  • Increased oversight across a broader segment of poorly performing facilities;
  • Modified formal oversight activities for high-performing facilities, provided adequate safeguards are in place and specified, real-time quality metrics of nursing homes continue to be met;
  • Greater use of enforcement remedies beyond civil monetary penalties, including directed plans of correction, temporary management, and chain-wide corporate integrity agreements, denial of admissions and termination from Medicare and Medicaid.
5B
Add the CAHPS measures of resident and family experience (i.e., the nursing home CAHPS survey) to Care Compare. 6A
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 to provide up-to-date, evidence-based education and guidance in best clinical and operational practices. Create explicit standards for these programs to promote comparable programs across states. 6E
Suggested Citation:"Appendix D: Recommendations by Responsible Partners." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
Combination of federal agencies, state governments, and nursing homes
Fund rigorous, pragmatic, 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. Research to focus on identifying models that reduce care disparities and strengthen connections between nursing homes, the communities in which they are located, and the broader health care and social services sectors. (Federal agencies [e.g., AHRQ, CMS, CMMI, CDC, NIH], private foundations, academic institutions, and long-term care provider organizations) 1B
To ensure the safety of nursing home residents, enforce existing regulations, including
  • Every nursing home has a written emergency plan (including evacuation plans) for common public health emergencies and natural disasters in the facility’s location, created in partnership with local emergency management and resident and family councils; plan reviewed and updated at least once every year.
  • Nursing home staff are to be routinely trained in emergency response procedures as well as in the appropriate use of PPE and infection control practices.
  • Every nursing home has 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/disaster.
1D
Documentation of emergency plans as well as the conduct of emergency drills and staff awareness of emergency management plans to be added to Care Compare. (CMS, through state regulatory agencies)
Develop incentives to support innovative, smaller, home-like designs for nursing home environments (both new construction and renovations) that support infection control and person-centered care and improve quality of life for residents. (CMS, and other governmental agencies) 1E
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. Consider the following mechanisms: wage floors, requirements for minimum percentage of service rates directed to labor costs for the provision of clinical care, wage pass-through requirements, and student loan forgiveness. (Federal and state governments, together with nursing homes) 2A
Update the regulatory requirements for staffing standards in nursing homes to reflect new minimum requirements and account for case mix based on research on minimum and optimum staffing standards for direct care staff. (CMS and state governments) 2C
Make available free entry-level training and continuing education for CNAs. (Federal, state governments, nursing homes) 2E
Provide flexible, low-cost, and high-quality pathways for nursing home staff to achieve baseline education and competency levels. (CMS and nursing homes) 2F
Suggested Citation:"Appendix D: Recommendations by Responsible Partners." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
Combination of federal agencies, state governments, and nursing homes
Impose oversight and enforcement actions on the owner 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). Actions may include: denial of new or renewed licensure, imposition of sanctions, and implementation of strengthened oversight (e.g., through a broadened special focus facilities program). (Federal and state oversight agencies [e.g., CMS, state licensure and survey agencies, DOJ]) 5D
Federal Emergency Management Agency
Reinforce and clarify the emergency support functions (ESFs) of the National Response Framework:
  • Revise ESF 8 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 to ensure that state and local emergency management documents and plans contain specific guidance for nursing homes during an emergency.
  • Revise ESF 15 to include nursing home residents as part of the target group of “individuals with disabilities and others with access and functional needs.”
1C
States
Ensure the development and ongoing maintenance of formal relationships, including strong interface, coordination, and reliable lines of communication, among nursing homes and local, county, and state-level public health and emergency management departments. (State regulatory agencies with federal oversight from FEMA and CMS) 1D
Ensure that nursing homes are represented in
  • State, county, and local emergency planning sessions and drills
  • Local government community disaster-response plans
  • Every phase of local emergency management planning, including mitigation, preparedness, response and recovery
  • Every nursing home has ready access to personal protective equipment
1D
(State emergency management agencies)
Ensure that all new nursing homes are constructed with single-occupancy bedrooms and private bathrooms for most or all residents. (State licensure agencies) 1E
Advocate for funds to LTC ombudsman programs to address cross-state variations in advocacy capability. 5C
Develop plans for LTC ombudsman programs to interface effectively with collaborating entities such as adult protective services, state survey agencies, and state and local law enforcement agencies. (State units on aging)
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. 5E
Suggested Citation:"Appendix D: Recommendations by Responsible Partners." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
Nursing Home Owners/Administrators
Ensure that each element of the resident care planning process is conducted in an accurate, comprehensive, and appropriate manner for each resident to promote person-centered high-quality care that reflects resident and family preferences. Interdisciplinary care team members make certain that every resident’s care plan addresses psychosocial and behavioral health as well as nursing and medical needs. Care plan to be reviewed and evaluated on a regular basis. (Nursing homes, with oversight by CMS) 1A
Construct and reconfigure (renovate) nursing homes to provide smaller, more home-like environments or smaller units within larger nursing homes with single-occupancy bedrooms and private bathrooms. This shift to more homelike 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. (Nursing home owners with the support of federal and state governmental agencies) 1E
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 improvement of care systems as needed to enhance available expertise. 2D
Provide career advancement opportunities and peer mentors for CNAs; cover CNAs’ time for completing education and training programs. 2E
Provide ongoing diversity and inclusion training (e.g., self-awareness of and approaches to addressing racism) for all workers and leadership, and ensure 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. 2G
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. 2G
Collect and report data to CMS regarding
  • Baseline demographic information of medical directors, administrators, and directors of nursing, including name, licensure, contact information, and tenure;
  • The geriatrics or long-term care training and expertise of medical directors, APRNs, social workers, physicians, and physician assistants;
  • The numbers and staffing patterns for these professionals; and
  • The numbers and staffing patterns for all contract and agency staff providing services in nursing homes.
2H
Suggested Citation:"Appendix D: Recommendations by Responsible Partners." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
Other partners (Private foundations, academic institutions, and long-term care provider organizations)
Prioritize and fund rigorous, pragmatic, 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. 1B
Include content related to gerontology, geriatric assessment, long-term care, and palliative care, with an additional preference for clinical experience in a nursing home in all education programs to prepare future health care professionals for their roles. (All education programs preparing health care professionals) 2F

NOTES: ACL = Administration for Community Living; AHRQ = Agency for Healthcare Research and Quality; APM = alternative payment model; APRN = advanced practice registered nurse; CAHPS = Consumer Assessment of Healthcare Providers and Systems; CDC = Centers for Disease Control and Protection; CE = continuing education; CMMI = Center for Medicare and Medicaid Innovation; CMS = Centers for Medicare & Medicaid Studies; CNA = certified nursing assistant; CSWE = Council on Social Work Education; DOJ = U.S. Department of Justice; EHR = electronic health record; ESF = emergency support function; FEMA = Federal Emergency Management Agency; HHS = U.S. Department of Health and Human Services; HIT = health information technology; HRSA = Health Resources and Services Administration; LGBTQ+ = lesbian, gay, bisexual, transsexual, queer, and others; LTC = long-term care; MDS = Minimum Data Set; MIPS = Merit-Based Incentive Payment System; NIH = National Institutes of Health; ONC = Office of the National Coordinator for Health Information Technology; PPE = personal protective equipment; RN = registered nurse.

Suggested Citation:"Appendix D: Recommendations by Responsible Partners." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
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Suggested Citation:"Appendix D: Recommendations by Responsible Partners." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
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Suggested Citation:"Appendix D: Recommendations by Responsible Partners." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
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Suggested Citation:"Appendix D: Recommendations by Responsible Partners." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
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Suggested Citation:"Appendix D: Recommendations by Responsible Partners." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
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Suggested Citation:"Appendix D: Recommendations by Responsible Partners." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
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Suggested Citation:"Appendix D: Recommendations by Responsible Partners." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
×
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Suggested Citation:"Appendix D: Recommendations by Responsible Partners." National Academies of Sciences, Engineering, and Medicine. 2022. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. Washington, DC: The National Academies Press. doi: 10.17226/26526.
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Nursing homes play a unique dual role in the long-term care continuum, serving as a place where people receive needed health care and a place they call home. Ineffective responses to the complex challenges of nursing home care have resulted in a system that often fails to ensure the well-being and safety of nursing home residents. The devastating impact of the COVID-19 pandemic on nursing home residents and staff has renewed attention to the long-standing weaknesses that impede the provision of high-quality nursing home care.

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

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