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Suggested Citation:"Appendix E: Recommendations Timeline." 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 E

Recommendations Timeline

While all of the recommendations in this report target areas that require immediate attention, the committee recognizes that some recommendations can be fully implemented immediately while others will require planning, coordination, and larger scale effort. Given this recognition of an incremental approach to the integrated set of recommendations, the committee has categorized each of the components of their recommendations according to an estimated implementation timeline. Recommendations that are

  • marked for immediate implementation are urgent, and largely can move ahead using existing structures.
  • identified for short- and intermediate-term implementation require action in the short-term to get started, but will require some amount of planning or coordination (such as the planning or coordination needed to initiate new studies or demonstration projects).
  • characterized as long-term implementation also require initiation in the shorter term, but the committee recognizes that full implementation may take several years (e.g., action dependent upon new research to be conducted or collaboration by multiple agencies across state and federal authorities).

The committee emphasizes that even those recommendations requiring intermediate or longer-term timeframes for complete implementation still need to be initiated now.

Suggested Citation:"Appendix E: Recommendations Timeline." 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.
×
Recommendation Rec
Immediate Implementation
Documentation of resident’s preferences in care plan and review and evaluation of its implementation 1A
Inclusion of explicit references to nursing homes in Emergency Support Functions 1C
Representation of nursing homes in all emergency and disaster planning and management sessions and drills 1D
  • Enforcement of existing regulations, including
  • Written emergency plan and emergency preparedness communication plan
  • Routine training of staff (emergency response procedures, use of personal protective equipment (PPE), infection control)
1D
Pathways for ready access to PPE 1D
Development of formal relationships between nursing homes and local, county, and state-level public health and emergency management departments 1D
Competitive wages and benefits for all nursing home staff 2A
Enhancement of the current minimum staffing requirements for every nursing home to include
  • Onsite direct-care registered nurse (RN) coverage at a minimum of 24/7 coverage
  • Additional RN coverage based on resident census, acuity, and case mix
  • Full-time social worker (with degree in social work and relevant experience)
  • Infection prevention and control specialist with sufficient dedicated time
2B
Coverage of certified nursing assistant (CNA) time for completing education and training programs 2E
Compliance with existing statute to determine adequacy of Medicaid payments to cover comprehensive care 4B
Adequate capacity and resources for state survey agencies to fulfill current oversight responsibilities 5A
Strong, consistent, responsive, and transparent process for grievances and complaints 5A
Greater use of variety of existing enforcement remedies 5B
Short-Term Implementation
Addition of documentation of emergency plans and staff training to Care Compare 1D
Enactment of state licensure decisions to ensure that all new nursing homes are constructed with single-occupancy bedrooms and private bathrooms for most or all residents 1E
Incentives for nursing homes to hire qualified licensed clinical social workers at the M.S.W. or Ph.D. level and advanced practice registered nurses (APRNs) for clinical care, including allowing Medicare billing and reimbursement for these services 2D
Free entry-level training and continuing education for CNAs (paid for by state and federal governments together with nursing homes) 2E
Minimum education and national competency requirements for all staff 2F
Annual continuing education for all nursing home staff 2G
Resources and training to support inclusion of chosen family members as part of caregiving team 2G
Suggested Citation:"Appendix E: Recommendations Timeline." 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.
×
Recommendation Rec
Ongoing diversity and inclusion training for all nursing home staff (including leadership) 2G
Data collection on baseline demographics, training and expertise, and staffing patterns for staff providing direct care 2H
Detailed facility-level data on the finances, operations, and ownership of all individual nursing homes 3A
Study of federal benefit design 4A
Specific percentage of payments designated for direct-care services (including staffing, behavioral health, and clinical care) 4C
Extension of bundled payment initiatives to all conditions 4D
Elimination of certificate-of-need requirements and construction moratoria 5E
Increased weight of staffing measures within five-star composite rating on Care Compare 6B
Identification of pathway to provide financial incentives for certified EHR adoption 7A
Short-Term Implementation (Initiation of Research and Grants)
Translational research and demonstration projects to identify the most effective nursing home care delivery models
  • Prioritize models that reduce disparities and strengthen connections to the community
  • Evaluate innovation in all aspects of care
1B
Research to identify and rigorously test specific minimum and optimum staffing standards for all direct-care staff 2C
Training grants to advance and expand the role of the CNA and develop new models of care delivery that leverage the role of the CNA as a member of the interdisciplinary care team 2E
Research on recruitment, training, and retention of all nursing home workers (particularly CNAs), including gender, ethnicity, and race-related outcomes of job quality indicators 2I
Demonstration projects to explore use of alternative payment models for long-term nursing home care tied to quality metrics 4E
Development and evaluation of strategies to improve quality assurance process 5B
Measures of disparities in nursing home care within and across facilities at national, state, and ownership levels 6D
Development of policies and culturally tailored interventions for disparities 6D
Development of new measures, including
  • Palliative care and end-of-life care;
  • Implementation of care plan;
  • Receipt of care that aligns with resident’s goals (and attainment of those goals);
  • Staff well-being and satisfaction;
  • Psychosocial and behavioral health;
  • HIT adoption and interoperability; and
  • Various structural measures
6C
Suggested Citation:"Appendix E: Recommendations Timeline." 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.
×
Development of new structural measures, including
  • Health information technology adoption and interoperability;
  • Percentage of single occupancy rooms;
  • Emergency preparedness, routine training in infection prevention;
  • Emergency response management; and
  • Financial performance; staff employment arrangements (e.g., full-time, part-time, contract and agency staff)
6C,
7B
Development and ongoing implementation of workforce training emphasizing core HIT competencies 7C
Research on use of HIT, existing structural disparities in HIT adoption, and their impact on resident outcomes 7D
Research on innovative HIT applications for resident care and assessment of clinician, resident, and family perceptions of HIT usability 7D
Intermediate-Term Implementation
Incentives to support innovative, smaller, home-like designs 1E
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 2D
Career advancement opportunities and peer mentors for CNAs 2E
Pathways for current workers to achieve minimum education and competency requirements 2F
Inclusion of geriatrics content in education programs for all health care professionals 2F
Real-time, readily usable, and searchable database that can evaluate and track quality of care for facilities with common ownership or management company 3B
Assessment of the impact of nursing home real estate ownership models and related-party transactions on quality of care 3B
Refine, expand, and report oversight performance metrics of state survey agencies 5A
Use of existing strategies of enforcement by CMS when states fall short of expected standards (based on performance metrics) 5A
Increased funding for long-term care ombudsman programs 5C
Imposition of oversight and enforcement actions on common owner (based on ability to track quality by owner [Recommendation 3B]) 5D
Collection of data for CAHPS measures and reporting on Care Compare 6A
Reporting of quality performance by common owner on Care Compare 6B
Improved validity of Minimum Data Set–based clinical quality measures on Care Compare 6B
Improved differentiation in five-star composite rating 6B
Development of overall health equity strategy for nursing homes 6D
Establishment of state-based technical assistance programs 6E
Minimum Data Set to identify and describe disparities in nursing homes (collected and reported annually) 6D
Measurement of levels of HIT adoption and interoperability and reporting of results in Care Compare 7B
Suggested Citation:"Appendix E: Recommendations Timeline." 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.
×
Recommendation Rec
Long-Term Implementation
Construction and reconfiguration (renovation) of nursing homes to provide smaller, more home-like environments, and/or smaller units within larger nursing homes 1E
Updated regulatory requirements for staffing standards in nursing homes to reflect completed research on minimum and optimum staffing standards for all direct-care staff 2C
Implementation of state demonstration projects based on study of federal benefit design 4A
Ongoing psychometric testing of CAHPS in nursing homes 6A
Adoption of new measures for reporting on Care Compare (as described under short-term implementation (initiation of research) 6C,
7B
Reporting of new measures of disparities in nursing home care 6D
Identification of thresholds for action on disparities, and promising pathways to reduce or eliminate disparities 6D
Evaluation of state-based technical assistance programs 6E
Measurement and reporting of clinician, resident, and family perceptions of HIT usability 7B
Suggested Citation:"Appendix E: Recommendations Timeline." 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 E: Recommendations Timeline." 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 E: Recommendations Timeline." 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 E: Recommendations Timeline." 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 E: Recommendations Timeline." 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.
×
Page576
Suggested Citation:"Appendix E: Recommendations Timeline." 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.
×
Page577
Suggested Citation:"Appendix E: Recommendations Timeline." 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.
×
Page578
The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff Get This Book
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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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