THE NATIONAL IMPERATIVE TO IMPROVE
NURSING HOME QUALITY
Honoring Our Commitment to Residents, Families, and Staff
Committee on the Quality of Care in Nursing Homes
Board on Health Care Services
Health and Medicine Division
A Consensus Study Report of
THE NATIONAL ACADEMIES PRESS
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This activity was supported by The John A. Hartford Foundation, The Commonwealth Fund, The Sephardic Foundation on Aging, Jewish Healthcare Foundation, and The Fan Fox & Leslie R. Samuels Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-68628-0
International Standard Book Number-10: 0-309-68628-8
Digital Object Identifier: https://doi.org/10.17226/26526
Library of Congress Catalog Number: 2022935879
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Copyright 2022 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America.
National Academies of Sciences, Engineering, and Medicine. 2022. The national imperative to improve nursing home quality: Honoring our commitment to residents, families, and staff. Washington, DC: The National Academies Press. https://doi.org/10.17226/26526.
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COMMITTEE ON THE QUALITY OF CARE IN NURSING HOMES
BETTY R. FERRELL (Chair), Director and Professor, City of Hope National Medical Center, Division of Nursing Research and Education
GREGORY L. ALEXANDER, Professor of Nursing, Columbia University School of Nursing
MARY ERSEK, Senior Scientist, Department of Veteran Affairs; Professor of Palliative Care, University of Pennsylvania Schools of Nursing and Medicine
COLLEEN GALAMBOS, Helen Bader Endowed Chair in Applied Gerontology and Professor, University of Wisconsin–Milwaukee; Adjunct Professor, Medical College of Wisconsin
DAVID C. GRABOWSKI, Professor of Health Care Policy, Harvard Medical School
KATHY GREENLEE, Chief Executive Officer, Greenlee Global LLC
LISA G. KAPLOWITZ, Physician Consultant, COVID Vaccine Unit, Virginia Department of Health
R. TAMARA KONETZKA, Louis Block Professor of Public Health Sciences, University of Chicago
CHRISTINE A. MUELLER, Professor and Senior Executive Associate Dean for Academic Programs, University of Minnesota School of Nursing
MARILYN J. RANTZ, Curators’ Professor Emerita, University of Missouri Sinclair School of Nursing
DEBRA SALIBA, Director, Borun Center and Professor of Medicine, University of California, Los Angeles; Physician Scientist, Geriatric Research Education and Clinical Center, Los Angeles Veterans Health Administration; Senior Natural Scientist, RAND
WILLIAM SCANLON, Consultant, West Health
PHILIP D. SLOANE, Goodwin Distinguished Professor of Family Medicine and Geriatrics, School of Medicine and Co-Director, Program on Aging, Disability and Long Term Care, Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
DAVID G. STEVENSON, Professor, Department of Health Policy, Vanderbilt University School of Medicine; VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center (GRECC)
JASMINE L. TRAVERS, Assistant Professor, Rory Meyers College of Nursing, New York University
REGINALD TUCKER-SEELEY, Vice President, Health Equity, ZERO-The End of Prostate Cancer; Edward L. Schneider Assistant Professor of Gerontology, Leonard Davis School of Gerontology, University of Southern California
RACHEL M. WERNER, Executive Director, Leonard Davis Institute of Health Economics; Professor of Medicine, University of Pennsylvania; Core Investigator, Crescenz Veterans Affairs Medical Center
LAURENE GRAIG, Study Director
TRACY A. LUSTIG, Study Director
KAITLYN FRIEDMAN, Associate Program Officer (through December 2021)
NIKITA VARMAN, Research Associate
RUKSHANA GUPTA, Research Assistant
MICAH WINOGRAD, Financial Officer
ANNE MARIE HOUPPERT, Senior Librarian
SHARYL J. NASS, Director, Board on Health Care Services
JOE ALPER, Science Writer
MARISA G. PINEAU, FrameWorks Institute
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by CHRISTINE K. CASSEL, University of California, San Francisco, and DAVID B. REUBEN, University of California, Los Angeles. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
The study committee and the Health and Medicine Division (HMD) project staff take this opportunity to recognize and thank the many individuals who shared their time and expertise to support the committee’s work and to inform deliberations.
This committee appreciates the sponsors of this study for their generous financial support: The John A. Hartford Foundation, The Commonwealth Fund, Jewish Healthcare Foundation, The Sephardic Foundation on Aging, and The Fan Fox & Leslie R. Samuels Foundation. The contents provided do not necessarily represent the official views of the sponsors.
The committee benefited greatly from discussions with individuals who made presentations during the committee’s open sessions and participated in the discussions:
The committee is very grateful to these presenters for volunteering to share their knowledge, data, and expert opinions with the committee and the members of the public who attended the committee’s open sessions. The committee also appreciates the many nursing home residents, families, and staff who submitted their perspectives and experiences.
Deep appreciation goes to staff at the National Academies of Sciences, Engineering, and Medicine for their efforts and support in the report process, especially to Dana Korsen, Stephanie Miceli, Devona Overton, Marguerite Romatelli, Tina Seliber, Lauren Shern, Leslie Sim, Dorothy Zolandz, and the staff of the National Academies Research Center, including Rebecca Morgan. The committee also gives special thanks to Joe Alper for
his writing and editing contributions, Marissa Pineau for her messaging and framing expertise, and Annalee Gonzales for her graphic design support.
Finally, the committee also recognizes and extends gratitude for all the nursing home residents, families, staff, and organizations that have fought tirelessly to improve nursing home care.
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Study Origin and Statement of Task
Previous Work of the National Academies
Conceptual Model of Nursing Home Quality
2 EVOLUTION AND LANDSCAPE OF NURSING HOME CARE IN THE UNITED STATES
Brief History of Nursing Homes
Current Nursing Home Population
Factors that Influence the Quality of Care in Nursing Homes
Strengthening Connections of Nursing Homes to the Community and Broader Health Care System
The Future of Nursing Home Care
3 QUALITY MEASUREMENT AND QUALITY IMPROVEMENT
The Purpose of Quality Measurement
Evolution of Quality Measurement in Nursing Homes
Care Compare and the CMS Five-Star Rating System
Resident- and Family-Reported Outcomes: Quality of Life, Experience of Care, and Satisfaction
Overview of Quality Improvement
Federal Initiatives for Quality Improvement
State and Local Initiatives for Quality Improvement
Other Approaches to Quality Improvement
Technical Assistance for Quality Improvement
Quality Improvement and Disparities
Coordinated Efforts During the COVID-19 Pandemic
The Future of Quality Improvement in Nursing Homes
Needs-Based Care for Nursing Home Residents
Assessing the Needs of Nursing Home Residents
Providing Care to Address Residents’ Needs
The Overall Nursing Home Workforce
Nursing Home Administration and Leadership
Nurse Staffing, Regulation, and Quality of Care
Infection Prevention and Control Leadership
Psychosocial and Spiritual Care Providers
Factors That Influence the Relationship Between Staffing and Quality
COVID-19 and Nursing Home Staffing
6 NURSING HOME ENVIRONMENT AND RESIDENT SAFETY
Ensuring the Safety of Nursing Home Residents
Nursing Home Emergency Planning, Preparedness, and Response
Variability between Medicare and Medicaid Payments
Value-Based Payment Models and the Impact on Quality of Care
8 QUALITY ASSURANCE: OVERSIGHT AND REGULATION
History of Quality Assurance in Nursing Homes
Omnibus Budget Reconciliation Act of 1987
CMS Oversight and Performance of the State Survey and Certification Processes
Long-Term Care Ombudsman Program
Effectiveness of Quality Assurance for Improving the Quality of Care
Transparency and Accountability
Nursing Home Oversight During COVID-19
9 HEALTH INFORMATION TECHNOLOGY
Evolution of Health Information Technology in Nursing Homes
Role of HIT in Quality Care in Nursing Homes
Challenges of HIT Adoption and Use in Nursing Homes
Other HIT Considerations for Quality Improvement
Committee Vision and Guiding Principles
Overarching Goals and Recommendations
Goal 1: Deliver Comprehensive, Person-Centered, Equitable Care that Ensures Residents’ Health, Quality of Life, and Safety; Promotes Autonomy; and Manages Risks
Goal 2: Ensure a Well-Prepared, Empowered, and Appropriately Compensated Workforce
Goal 3: Increase Transparency and Accountability of Finances, Operations, and Ownership
Goal 4: Create a More Rational and Robust Financing System
Goal 5: Design a More Effective and Responsive System of Quality Assurance
Goal 6: Expand and Enhance Quality Measurement and Continuous Quality Improvement
Goal 7: Adopt Health Information Technology in All Nursing Homes
What Would Quality Nursing Home Care Look Like?
B Examples from the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents
C Recommendations by Area of Measurement and by Area of Research
D Recommendations by Responsible Partners
The Committee on the Quality of Care in Nursing Homes began their work in the fall of 2020 at a pivotal time when a bright light had been cast on care delivered in nursing homes because of the COVID-19 pandemic. While much of society previously had little awareness of the care delivered in nursing homes, the evening news channels and social media projected daily images of the pandemic’s impact and of the inadequate care that put the safety of both residents and staff at risk while distraught family members watched from afar as their frail older loved ones were kept in isolation. The committee worked to describe the care being delivered in nursing homes before the pandemic, now made manifest by the crisis.
The committee was given a substantial task of examining how the United States “delivers, finances, measures, and regulates the quality of nursing home care.” The challenge was enormous, but as reflected in the final recommendations, real change in nursing home care will require bold action in each of these domains. In the report chapters that follow, the committee presents the evidence of the need for change followed by specific recommendations. The final chapter concludes that “the way the United States finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, fragmented, and unsustainable.”
The discussions of the committee often centered around core values of a society that truly cares for the most vulnerable. We began our work with creating a word map of key words and phrases that described what we all hoped for in nursing home care. Words such as safety, equity, peaceful, joyous, integrity, and comfort were often shared as we all imagined what care in a nursing home should be. The committee members were constantly
aware of the data, literature, and daily news stories of the travesties in nursing home care as they wrote this report. The committee also recognized the many examples of outstanding care being provided in nursing homes and realized that across the United States nursing home staff representing all disciplines are each day providing wonderful care to residents who they consider as beloved family members. Sadly, these staff have put their own lives at risk and are often not well trained, supported, or compensated. This report and the committee’s recommendations assert strongly that residents of nursing homes need better care—and the people caring for them also need better care. The committee report is clear that we will not realize good-quality care of residents until we invest in the bedside staff who care for them.
The committee often reflected on the 1986 Institute of Medicine report Improving the Quality of Care in Nursing Homes, which was a critical milestone yet whose recommendations were not fully realized. As a nation we have made promises for better care in nursing homes, and those promises have not been kept. Our hope is that commitment and promises for quality nursing home care that were voiced throughout the pandemic will become promises kept. The recommendations from the committee are thoughtful and strategic. Perhaps the committee’s biggest challenges came when we tried to balance the need for very aggressive, overdue change with the reality of limited resources, competing priorities, and the complexity of systems change. We believe the recommendations in this report achieve that balance of what is possible and what is desperately needed.
Is it too much to ask that each and every resident in every nursing home receives care that includes high-quality physical care, behavioral health, safety, and psychological support? Is it too much to ask for a plan of care to establish what is most needed for each resident to receive high-quality care that is truly person centered? Are we too bold to recommend on-site registered nurse coverage in nursing homes, a social worker, and an infection control specialist? After all that we have witnessed during the COVID-19 pandemic, is it too much to ask that nursing assistants are better trained to deliver care to often frail people with limited social support or resources in the last years of their lives? It is not too much to ask that all residents receive good-quality care regardless of race, ethnicity, or geographic location? In fact, the recommendations in this report are no more than what any one of us would want for ourselves or for those we love if we or they were in a nursing home. How can we not accept the committee’s recommendations and profoundly change the delivery of care in U.S. nursing homes?
As with the evaluation of most areas of significant importance to our society, adopting and implementing the recommendations of this report will require more than funding, organizational commitment, education, and changing health policy—it will require moral courage. Improving the
quality of care in nursing homes for the decades ahead will be a continuing process requiring research to strengthen our knowledge of best care, test models to deliver that care, and investment in the education and training of all of those who work in nursing homes. The recommended approach is bold, but it is possible. But most importantly, it is right. Indeed, improving nursing home care is a moral imperative because it is clearly the right thing to do. It is also a national imperative because it represents society’s commitment to caring for those who cannot care for themselves.
It has been a great privilege to have served as chair of this committee. This report will be published as I celebrate my 45th year as a nurse, and I consider it one of the highlights of my career to have devoted over a year to working with this committee of some of the most dedicated colleagues I have known. Most have devoted their careers to advocating for improved care in nursing homes—a pursuit that has not been well funded, often recognized, or rewarded. These members each brought their knowledge and their passion for improved care to the table.
We are in great debt to the staff of the National Academies for their commitment to this work. Laurie Graig and Tracy Lustig as senior program staff led the project with the greatest integrity and vision. The entire staff of the National Academies, including Kaitlyn Friedman, Nikita Varman, and Rukshana Gupta, offered their dedication, organization, and energy to a task that at times seemed overwhelming.
As a nation, we will hopefully see the COVID-19 pandemic resolve in the months that will follow the release of this report. It will be too easy to turn our eyes away from the reform needed in nursing home care. This is the moment; this is the time to keep the promise of better care for those who are the most vulnerable in our society. The committee has delivered the blueprint to build a system of care that honors those who call the nursing home their home and the dedicated staff who care for them. Improving care in nursing homes is possible. It can be done. It must be done.
Betty Ferrell, Ph.D., FAAN, FPCN, CHPN, Chair
Committee on the Quality of Care in Nursing Homes
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Acronyms and Abbreviations
|AADNS||American Association of Directors of Nursing Services|
|ABPLM||American Board of Post-Acute and Long-Term Care Medicine|
|ACA||Patient Protection and Affordable Care Act|
|ACL||Administration for Community Living|
|ACO||accountable care organization|
|ACP||advance care planning|
|ADE||adverse drug event|
|ADL||activity of daily living|
|ADRD||Alzheimer’s disease and related dementias|
|AHCA||American Health Care Association|
|AHRQ||Agency for Healthcare Research and Quality|
|AMDA||Society for Post-Acute and Long-Term Care Medicine|
|AONL||American Organization for Nursing Leadership|
|APM||alternative payment model|
|APRN||advanced practice registered nurse|
|APS||adult protective services|
|ATOP||Nevada Admissions and Transitions Optimization Program|
|BIPOC||Black, Indigenous, and other people of color|
|BPCI||Bundled Payments for Care Improvement Initiative|
|BSW||bachelor’s degree in social work|
|CAH||critical access hospital|
|CAHPS||Consumer Assessment of Healthcare Providers and Systems|
|CASPER||Certification and Survey Provider Enhanced Reporting|
|CDC||Centers for Disease Control and Prevention|
|CHIP||Children’s Health Insurance Program|
|CJR||Comprehensive Care for Joint Replacement Model|
|CLASS Act||Community Living Assistance Services and Supports Act|
|CMMI||Center for Medicare and Medicaid Innovation|
|CMS||Centers for Medicare & Medicaid Services|
|CNA||certified nursing assistant|
|COVID-19||severe acute respiratory syndrome coronavirus-19 (SARS-CoV-2)|
|C-SNP||chronic condition special needs plan|
|CSWE||Council on Social Work Education|
|DHS||U.S. Department of Homeland Security|
|DNR||do not resuscitate|
|DOJ||U.S. Department of Justice|
|D-SNP||dual special needs plan|
|ECHO||Extension for Community Healthcare Outcomes|
|EHR||electronic health record|
|eMAR||electronic medication management system|
|EMR||electronic medical record|
|ESF||emergency support function|
|FEMA||Federal Emergency Management Agency|
|FIDE||fully integrated dual eligible|
|GAO||U.S. Government Accountability Office|
|HAI||health care–associated infection|
|HHS||U.S. Department of Health and Human Services|
|HIE||health information exchange|
|HIT||health information technology|
|HITECH||Health Information Technology for Economic and Clinical Health Act of 2009|
|HRSA||Health Resources and Services Administration|
|HUD||U.S. Department of Housing and Urban Development|
|IHI||Institute for Healthcare Improvement|
|INTERACT||Interventions to Reduce Acute Care Transfers|
|IOM||Institute of Medicine|
|I-SNP||institutional special needs plan|
|LGBTQ+||lesbian, gay, bisexual, transgender, queer (or questioning), and others|
|LPN||licensed practical nurse|
|LTSS||long-term services and supports|
|LVN||licensed vocational nurse|
|MCWB||Mouth Care Without a Battle|
|MDS||Minimum Data Set|
|MedPAC||Medicare Payment Advisory Commission|
|MIPS||Merit-Based Incentive Payment System|
|MOQI||Missouri Quality Initiative|
|MSW||master’s degree in social work|
|NAICS||North American Industry Classification System|
|NASW||National Association of Social Workers|
|NCAL||National Center for Assisted Living|
|NIH||National Institutes of Health|
|NNHI||National Nursing Home Initiative|
|NQF||National Quality Forum|
|NRF||National Response Framework|
|NY–RAH||New York–Reducing Avoidable Hospitalizations|
|OBRA 87||Omnibus Budget Reconciliation Act of 1987|
|OIG||U.S. Office of the Inspector General|
|ONC||Office of the National Coordinator for Health Information Technology|
|OPTIMISTIC||Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care|
|OTC||over the counter|
|PASRR||preadmission screening and annual resident review|
|PDPM||patient-driven payment model|
|PIPP||Minnesota Performance-Based Incentive Payment Program|
|POLST||physician’s order for life-sustaining treatment|
|PPE||personal protective equipment|
|QAPI||quality assurance and performance improvement|
|QIO||Quality Improvement Organization|
|QIPMO||Quality Improvement Program for Missouri|
|QOL||quality of life|
|RAI||Resident Assessment Instrument|
|RAVEN||Reduce Avoidable Hospitalizations using Evidence-Based Interventions for Nursing Facilities|
|REIT||real estate investment trust|
|SAPO||state-authorized portable order|
|SCTT||Systems Change Tracking Tool|
|SFF||Special Focus Facility|
|SMI||serious mental illness|
|SNF||skilled nursing facility|
|SNFist||skilled nursing facility specialist|
|SNP||special needs plan|
|VA||U.S. Department of Veterans Affairs|
|VHA||Veterans Health Administration|
|WISH Act||Well-Being Insurance for Seniors to be at Home Act|
Nursing homes play a unique dual role in the nation’s long-term care continuum, serving both as a place where people receive needed health care and a place they call home. Although long-term care is increasingly being provided in home- and community-based settings, nursing homes will likely always be needed for individuals who cannot get the level of care they require in those settings. The 1986 Institute of Medicine1 report Improving the Quality of Care in Nursing Homes described numerous concerns, including neglect and abuse of nursing home residents, poor quality of life, excessive cost, inconsistent (or lack of) oversight, and the need for high-quality data. While many improvements have been made since then, the enormous toll that the COVID-19 pandemic had on nursing home residents, their families, and staff has brought new attention to the longstanding shortfalls that continue to plague nursing homes.
This report identifies critical opportunities to improve the quality of care in nursing homes through both short- and long-term actions across a wide variety of domains. Many recommendations will require dedicated coordination among federal and state governments, nursing homes, health care and social care providers, payers, regulators, researchers, and others as well as the active engagement of residents and their families. The nursing home sector urgently needs to be strengthened so that it can
1 As of March 2016 the Health and Medicine Division of the National Academies of Sciences, Engineering and Medicine (National Academies) continues the consensus studies and convening activities previously carried out by the Institute of Medicine (IOM). The IOM name is used to refer to reports issued prior to July 2015.
respond effectively to the next public health emergency as well as drive critically important and urgently needed innovations to improve the quality of nursing home care. Implementation of the committee’s integrated set of recommendations will move the nation closer to making high-quality, person-centered, and equitable care a reality for all nursing home residents, their chosen families, and the nursing home staff who provide care and support them in achieving their goals.