The National Imperative to Improve Nursing Home Quality Honoring Our Commitment to Residents, Families, and Staff (2022) / Chapter Skim
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Although long-term care is increasingly provided in home and community-based settings, nursing homes will likely always be needed for individuals who have complex care needs, are without family or friends able to assist with their care, or lack the resources to be cared for at home. The 1986 Institute of Medicine1 report Improving the Quality of Care in Nursing Homes identified a variety of significant problems, including neglect and abuse of residents, poor quality of life, excessive cost, inconsistent (or lack of)
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The pandemic's enormous toll on nursing home residents and staff drew renewed attention to the long-standing weaknesses that continue to impede the provision of high-quality nursing home care. In this context, the National Academies of Sciences, Engineering, and Medicine, with support from a coalition of sponsors, formed the Committee on the Quality of Care in Nursing Homes in 2020 to examine how the United States delivers, finances, regulates, and measures the quality of nursing home care.2 OVERARCHING CONCLUSIONS After an extensive review of the evidence, the committee arrived at seven overarching conclusions.
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Those same shortcomings rendered nursing homes, their residents, and staff unprepared to respond to the COVID-19 pandemic. Third, 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.
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. While the committee's vision identifies what high-quality nursing home care should look like, the guiding principles serve as a strong reminder that existing regulations require nursing homes to provide comprehensive, personcentered care.
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High-quality nursing home care provides an environment that promotes quality of life; aligns with residents' medical, behavioral, and social care needs; reflects residents' values and preferences; promotes autonomy; and manages risks to ensure residents' safety. Such comprehensive, high-quality care includes the following, as appropriate: • Physical health care • Behavioral health care • Psychosocial care • Oral health care • Hearing and vision care • Rehabilitative care • Dementia care • Palliative care • End-of-life care Furthermore, it is the right of every nursing home resident to have equitable access to high-quality comprehensive, person-centered, and culturally sensitive nursing home care.
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Moreover, significant disparities in the quality of care also exist across nursing homes. Care Planning The resident care planning process has a central role in the full realization of person-centered, comprehensive, high-quality, and equitable care in the nursing home setting.
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To safeguard nursing home residents and staff against a broad range of potential public health emergencies and natural disasters, Recommendations 1C and 1D call for the following: • Reinforcement and clarification of the emergency support functions of the National Response Framework; • Formal relationships between nursing homes and local, county, and state-level public health and emergency management departments; • The representation of nursing homes in emergency and disaster planning and management sessions and drills; • Ready access to personal protective equipment; • Enforcement of existing regulations; and • Inclusion of measures related to emergency planning in Care Compare. Physical Environment Although the nursing home's physical environment is critical to residents' quality of life, the nursing home infrastructure is aging, and most nursing homes resemble institutions more than homes.
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The committee recommends increasing both the numbers and the qualifications of virtually all types of nursing home workers, which can exacerbate the challenges of recruitment. The committee recognizes that such a recommendation is particularly concerning given the current dire staffing situations for many nursing homes, largely due to the impact of the COVID-19 pandemic.
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Furthermore, CMS has not established minimum staffing requirements for certain key members of the interdisciplinary team. For example, despite social workers' key role in resident care, current federal regulations require only those nursing homes with 120 or more beds to hire a "qualified social worker" on a full-time basis.
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Furthermore, CNAs often have little opportunity for advancement. Because of the crucial role of this position in nursing homes, significantly improving the quality of care for nursing home residents requires investing in quality jobs for CNAs and enabling more workers to enter the CNA pipeline.
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. Data Collection and Research In addition to enhanced requirements for nursing home staff, a greater number of more highly trained professionals need to be involved in the delivery of care in nursing homes.
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; and do not allow for determining the corporate structure, finances, and operations of individual nursing homes or assessing quality across facilities owned or operated by the same entity. Moreover, there is little transparency regarding the practice of some nursing homes to contract with related-party organizations (those also owned by the nursing home owner)
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The federal-state Medicaid program plays a dominant role as a payer of long-stay nursing home care, but is constantly subject to state budget constraints. The federal Medicare program only covers short-stay post-acute care in nursing homes.
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Ensuring Adequacy of Medicaid Payments Nursing homes rely on higher payments for Medicare services to cross-subsidize lower Medicaid payments -- an inefficient and unsustainable arrangement. Many nursing homes have a high number of Medicaid recipients and therefore receive relatively little benefit from higher Medicare payments.
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, behavioral health, and clinical care. Value-Based Payment for Nursing Home Care Nursing homes are one of the most common sites of post-acute care.
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State Surveys and CMS Oversight States assist with the assessment of nursing homes' compliance with CMS requirements of participation through regular inspections and, as necessary, the investigation of complaints. Although federal oversight standards and processes are uniform across states, considerable variation exists in the implementation of routine inspection responsibilities, in the imposition of sanctions, and in the investigation of complaints.
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to suggest which approaches would ultimately lead to improvement in the quality of care for nursing home residents. Recommendation 5B calls for the following: • Developing and evaluating strategies to improve quality assurance efforts, including • Enhanced data monitoring to track performance and triage inspections; • Oversight across a broader segment of poorly performing facilities; • Modified formal oversight activities for high-performing facili ties, provided adequate safeguards are in place; and • Greater use of enforcement options beyond civil monetary penalties.
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Quality Assurance, Transparency, and Accountability As noted earlier, the committee concluded that increased transparency and accountability will help to improve the quality of care. For quality assurance, the availability of more accurate and complete data on the finances, operations, and ownership of nursing homes will enable regulators to assess the quality of care across facilities with a common owner and levy sanctions as appropriate.
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Eliminating such restrictive policies is not intended as a mechanism to increase the use of nursing homes or invest in nursing homes in lieu of other settings for long-term care. Rather, the committee seeks to expand consumer choice for those who need and choose nursing home care.
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However, the lack of robust data specific to race and ethnicity in nursing homes makes it difficult to document the true extent and impact of disparities in care. 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.
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Nursing home residents often have complex medical conditions that require care coordination among specialists in hospitals and other care settings, further underscoring the need for nursing homes to have EHRs that communicate with other systems to ensure smooth and safe care transitions as patients move from one health care setting to another. While federal programs provided incentives to eligible health care professionals and hospitals to support EHR adoption, nursing homes were not designated as eligible for such incentives.
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If HIT is to realize its potential to improve the quality of care and increase staff productivity, it will require training nursing home leadership and staff, among other factors. However, despite evidence that training is a key contributor to staff satisfaction with HIT, most nursing homes do not provide adequate training.
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The COVID-19 pandemic provided powerful evidence of the deleterious impact of inaction and inattention to long-standing quality problems on residents, families, and staff. 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.
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