The National Imperative to Improve Nursing Home Quality Honoring Our Commitment to Residents, Families, and Staff (2022) / Chapter Skim
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10 Recommendations
10 Recommendations
Pages 495-542
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From page 495... ...
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.
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From page 496... ...
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.
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From page 497... ...
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. COMMITTEE VISION AND GUIDING PRINCIPLES As a framework for this study, the committee created an original conceptual model of high-quality care in nursing homes (see Chapter 1)
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From page 498... ...
CMS BOX 10-1 Committee Vision and Guiding Principles for High-Quality Nursing Home Care COMMITTEE VISION: Nursing home residents receive care in a safe environment that honors their values and preferences, addresses the goals of care, promotes equity, and as sesses the benefits and risks of care and treatments. GUIDING PRINCIPLES: To achieve this vision, nursing homes should deliver comprehensive, person centered, interdisciplinary team-based care that meets or exceeds established quality standards and supports strong connections to health care and social service systems and resources, family, friends, and the community more broadly.
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From page 499... ...
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.
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From page 500... ...
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)
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From page 501... ...
, 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)
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From page 502... ...
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)
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From page 503... ...
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.
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From page 504... ...
• 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.
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From page 505... ...
should be revised to give greater prominence to nursing homes with the goal of clarify ing that nursing homes specifically, and long-term care facilities more broadly, are included within ESF 8 (Public Health and Medi cal Services) to ensure that state and local emergency management documents and plans contain specific guidance for nursing homes during an emergency.
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From page 506... ...
should ensure the development and ongoing maintenance of formal relationships, including strong interface, coordination, and reliable lines of com munication, 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 in cluding mitigation, preparedness, response and recovery.
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From page 507... ...
and need to receive periodic training to refresh and update their skills and knowledge. Physical Environment It is critical to recognize that nursing homes serve dual roles: care settings as well as places in which people reside.
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From page 508... ...
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. Compensation Nursing home workers earn significantly less in nursing homes than if they chose to work in other care settings.
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From page 509... ...
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.
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From page 510... ...
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.
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From page 511... ...
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.
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• CMS should create incentives for nursing homes to hire qualified licensed clinical social workers at the M.S.W.
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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)
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From page 514... ...
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.
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From page 515... ...
. 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.
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• 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.
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From page 517... ...
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.
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From page 518... ...
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.
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From page 519... ...
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.
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From page 520... ...
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.
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From page 521... ...
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.
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From page 522... ...
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.
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From page 523... ...
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.
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From page 524... ...
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.
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From page 525... ...
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)
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From page 526... ...
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.
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From page 527... ...
; • 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 com plaints, 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 penal ties, including chain-wide corporate integrity agreements, denial of admissions, directed plans of correction, temporary management, and termination from Medicare and Medicaid.
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From page 528... ...
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.
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From page 529... ...
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.
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From page 530... ...
Effective quality measures can be used for continuous quality improvement activities. Quality Measurement The CMS website Care Compare provides public reporting of quality measures for nursing homes.
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From page 531... ...
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)
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From page 532... ...
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.
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From page 533... ...
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.
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From page 534... ...
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.
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From page 535... ...
GOAL 7: ADOPT HEALTH INFORMATION TECHNOLOGY IN ALL NURSING HOMES 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
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From page 536... ...
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.
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From page 537... ...
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, consis tent 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 per ceptions of HIT usability.
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From page 538... ...
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 WHAT WOULD QUALITY NURSING HOME CARE LOOK LIKE? 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.
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From page 539... ...
Care coordination would include seamless transitions to other settings of care (as needed) , and all nursing homes would have stateof-the-art health information systems to facilitate the sharing of information across care settings.
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From page 540... ...
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.
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From page 541... ...
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.
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