The National Imperative to Improve Nursing Home Quality Honoring Our Commitment to Residents, Families, and Staff (2022) / Chapter Skim
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2 Evolution and Landscape of Nursing Home Care in the United States
2 Evolution and Landscape of Nursing Home Care in the United States
Pages 47-88
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This chapter documents the history, evolution, and current landscape of nursing home care in the United States and sets the stage for the report's subsequent chapters, which provide the evidence base for the committee's recommendations for delivering high-quality nursing home care. BRIEF HISTORY OF NURSING HOMES Historically, families were responsible for the majority of care for older adults or people with disabilities.
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population seeking care in nursing homes. Today, alternative long-term care settings exist, and nursing home residents' level of acuity and case mix have shifted due to the availability of post-acute care, palliative care, and hospice options.
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(See Chapter 4 for further discussion about culture change in nursing homes.) Most recently, the need for a more balanced approach between clinical care and ensuring quality of life in a home-like setting became even more evident by the catastrophic impact the COVID-19 pandemic had on nursing home care, residents, and staff.
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Residents under 65 are the most rapidly growing age group in nursing homes, despite the Healthy People 2010 and 2020 goals of shifting care of children and young adults out of nursing homes and into home- and community-based settings (Jin and Agrawal, 2017)
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commonly present to nursing homes with chronic conditions (e.g., diabetes, chronic obstructive pulmonary disease, asthma, renal failure, or circulatory/ heart conditions)
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Disparities A myriad of factors contribute to resident racial and ethnic disparities within and between nursing homes, including (1) limited clinical resources, (2)
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are more likely than Black or Hispanic residents to receive care in nursing homes with Alzheimer's special care units, which results in better health outcomes (Rivera-Hernandez et al., 2019)
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. Another study found that Black residents were more likely than White residents to be dually eligible for Medicare and Medicaid and less likely to be admitted to nursing homes with four- or five-star ratings (Yan et al., 2021; see also Sharma et al., 2020)
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. This segregation contributes to consistently worse health outcomes in nursing homes for racial and ethnic minority populations, particularly if they are of lower socioeconomic status (Bowblis et al., 2021; Travers et al., 2021)
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. Care Needs and Services Provided To care for people with a variety of conditions, nursing homes provide a spectrum of services, including skilled nursing and medical care, 24-hour supervision, hospice and end-of-life care, treatments related to bladder or bowel incontinence, and assistance with ADLs.
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. The majority of nursing homes provide both short-term rehabilitation and subacute care.6 Individuals receiving subacute care have variations in the intensity of their care needs and the stability of their conditions.
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, an average of 21 percent of all deaths and 27 percent of all deaths among individuals at least 65 years old in the United States occurred in nursing homes or long-term care facilities (CDC, 2020b)
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. The VA provides long-term care in three settings classified as nursing homes: approximately 134 community living centers (VA owned and operated)
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. Pediatric Nursing Homes Pediatric nursing homes are also available for those under the age of 21.
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Similar to adult nursing homes, pediatric nursing homes typically provide skilled nursing care, occupational therapy, and recreational therapy (Children's National Hospital, 2021; Hessels et al., 2017; Nursing Home Law Center, 2010; Stein, 2001)
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. Children and young adults living in adult nursing homes can be vulnerable to a variety of forms of mistreatment or abuse, including sexual abuse, physical abuse, neglect, molestation, and medication errors (Nursing Home Law Center, 2010)
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Quality Measurement and Quality Improvement Ensuring and improving the quality of care in nursing homes requires measuring it in order to inform consumers, hold providers and organizations accountable, and support evidence-based treatments and interventions. The current system for quality measurement in nursing homes is the CMS Five-Star Rating System, which establishes a score based on health inspections, staffing levels, and clinical outcomes.
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. Given that state Medicaid programs play a large role in paying for long-term nursing home care, competition among nursing homes is limited, which can limit incentives to improve quality.
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. Private equity firms own approximately 11 percent of nursing homes (Gupta et al., 2021; Spanko, 2020)
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CRITICAL IMPACT OF COVID-19 ON NURSING HOMES As of August 2020, nearly half (42 percent) of COVID-related deaths in the United States since the beginning of the pandemic had occurred in nursing homes and assisted living facilities (AP, 2020)
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Infection Prevention and Control Challenges Another factor shaping the COVID-19 pandemic's effect was that nursing homes did not have adequate expertise and experience in the infection prevention and control practices necessary to limit the introduction and transmission of the virus within facilities (Grabowski and Mor, 2020)
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, these delays also facilitated spread of infection. Although CMS, CDC, state departments of health, and others issued infection control guidance, its volume and frequent changes posed significant challenges to nursing homes, which struggled to interpret, keep up with, and adapt to the latest guidance.
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. Disparities Among Nursing Home Residents During COVID-19 In the first 6–8 months of the pandemic, nursing homes serving more than 40 percent non-White residents experienced more than three times as many COVID-19 cases and deaths as those serving primarily White residents (Gorges and Konetzka, 2021)
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In addition, nursing homes severely limited or prevented visitation by family members and loved ones to align with CMS directives, which exacerbated the impact of social isolation and loneliness. There were delays in identifying ways to address this isolation while also limiting residents' exposure to the virus (Montgomery et al., 2020)
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. Vaccination Challenges Introducing vaccines and prioritizing their distribution in long-term care facilities in late December 2020 greatly alleviated the impact of COVID-19 in nursing homes, whose vaccination rate is much higher than the national average (CDC, 2021c; CMS, 2021b)
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High-quality nursing homes were also at risk. This does not mean that quality and infection prevention and control are not important, but perhaps they are not sufficient.
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. Forging effective relationships, strengthening communication, and creating partnerships between nursing homes and hospitals and academic medical centers are critical given that residents often require care in these settings for their often multiple complex medical conditions.
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. THE FUTURE OF NURSING HOME CARE Nursing homes within the long-term care continuum in the United States are characterized by a disjointed system with a lack of data, different funding streams, variable oversight, and insufficient communication -- all of which combine to make quality improvement extremely difficult (Goldberg, 2014)
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Designed to improve the quality of care through significant changes in key areas, including workforce, regulation, financial transparency, and accountability, the proposed legislation, if enacted, would • Increase the federal Medicaid payment to states for the next 6 years, • Require that funds allocated are used to increase staff pay and expand staffing in order to support and improve resident care, • Require a registered nurse on duty 24/7, • Require a full-time infection control specialist, • Require nursing facilities to report more accurate quality and staff ing data to the government, • Fund a study to determine whether the government should set minimum staffing ratios at nursing homes, • Ban facilities from mandating that residents sign pre-dispute arbi tration agreements, and • Create a $1.3 billion demonstration program to encourage the construction of facilities that house 5–14 residents. This legislation addresses many changes necessary to improve quality of care, such as increasing funding, enforcing staffing requirements, and creating smaller facilities.
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nursing homes with COVID-19 cases. Journal of the American Geriatrics Society 68(8)
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2021d. Interim infection prevention and control recommendations to prevent SARS CoV-2 spread in nursing homes.
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2018. The physical environment of nursing homes for people with dementia: Traditional nursing homes, small-scale living facilities, and green care farms.
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nursing homes. Journal of the American Geriatrics Society 68(11)
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2020. The long-term care pandemic: International perspectives on COVID-19 and the future of nursing homes.
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2015. Multilevel examination of facility char acteristics, social integration, and health for older adults living in nursing homes.
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Nursing homes. Journal of the American Geriatrics Society 68(11)
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2021. COVID-19 had a devastating impact on Medicare beneficiaries in nursing homes during 2020.
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in nursing homes. Journal of the American Medical Directors Association 11(7)
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2020. Does living in a higher proportion minority facility improve quality of life for racial/ethnic minority residents in nursing homes?
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2021. Geriatrics and extended care: Residential set tings and nursing homes.
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2021. Admissions to high-quality nursing homes from community: Racial differences and Medicaid policy effects.
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