A special commission looking into the large number of cases and deaths from COVID-19 in nursing homes says numerous changes are needed now, to mitigate further risk during this pandemic and avoid similar problems in the future. The commission’s final 186-page report, released Sept. 16, proposed 27 main recommendations grouped into 10 themes to improve infection prevention and control measures, safety procedures, and the quality of life of residents within nursing homes.
The 25-member Coronavirus Commission for Quality and Safety in Nursing Homes was formed last spring to address serious problems in long-term care facilities, which account for some 40% of COVID-related deaths in the United States. The Commission convened nine times between June 23 and Aug. 19. Experts – including those in government, academia, consumer advocacy and long-term care management – examined lessons learned from the early days of the pandemic and focused on actions that CMS has the authority to implement immediately or within the next six months. The commission’s work was overseen by the MITRE corporation, an independent not-for-profit contracted by the Department of Health and Human Services (HHS), which advises them on health care delivery and systems. Each suggestion includes specific action steps and information about the Commission’s endorsement.
“In tasking a contractor to convene this independent Commission comprised of a broad range of experts and stakeholders, President Trump sought to refine our approach still further as we continue to battle the virus in the months to come,” said CMS Director Seema Verma in a statement. “Its findings represent both an invaluable action plan for the future and a resounding vindication of our overall approach to date. We are grateful for the Commission’s important contribution.”
The report is organized around 10 major themes: testing and screening; equipment and PPE; cohorting; visitation; communication; workforce ecosystem; technical assistance and quality improvement; facilities; and nursing home data. Commission members described the primary problems associated with each, CMS’s response to date and emerging evidence, along with principal recommendations and action steps. Among the key recommendations, the report says CMS should:
- Immediately develop and execute a national strategy, coordinating with federal, state, local and territorial authorities, for testing and delivering rapid turnaround of results (less than 24 hours)
- Procure and sustain a three-month supply of high-quality supplies of PPE and train all clinical and non-clinical facility staff on its proper use.
- Update cohorting to balance resident and staff psychological safety and well-being with infection prevention and control.
- Update and release consolidated, evidence-based guidance on safely increasing controlled, in-person visitation prior to federal Phase 3 reopening as well as plan for and implement virtual visitation tools and techniques.
- Provide guidance that allows nursing home workforce members to safely continue to work in multiple nursing homes, adhering to infection prevention and control practices.
- Identify and immediately leverage certified infection preventionists to support nursing homes’ infection prevention needs. Require nursing homes to employ infection preventionist(s) with educator capabilities.
- Identify and share short-term facility design enhancements to address immediate pandemic-related risks that can be implemented at minimal cost.
- Identify and share best practices and recommendations and real-time learning on best use of existing physical spaces
- Standardize COVID-19 data elements, improve data collection, and identify actions that CMS and federal partners will take in response to key COVID-19 indicators based on nursing home-reported data
Additionally, the commission recommends CMS establish long-term priorities and seek appropriate funding streams for nursing homes to redesign and/or strengthen facilities against infectious diseases; help improve communications between nursing home staff, residents, and families; overhaul the professional workforce, including on-the-job CNA training, testing, and certification; create a national CNA registry and professionalize infection prevention positions. CMS should also create an easy-to-use, intuitive, and interactive technical infrastructure for nursing homes that streamlines the process of data reporting and consolidates dissemination of essential policy guidance, information about updated regulations, and other communications.
Not all commission members agreed with every recommendation; the report also noted that one member — Eric M. Carlson, J.D., directing attorney, Justice in Aging, California does not endorse this report. Carlson said in his dissenting statement:
“The Final Report recommends dozens of obligations for the federal government, but does little to set higher standards for nursing homes, or to ensure nursing home accountability. A more balanced report would appropriately allocate responsibility to all parties – including nursing home operators – with a sense of urgency commensurate to the current crisis.”
The commission members noted that systemic problems, including financing, fiscal accountability, facility design, workforce, governance/management, technology, data and research significantly contributed to the challenges of preventing and treating COVID-19 in nursing homes. Among them: a fragmented delivery system, a patchwork of federal, state and local regulations, workforce issues, including “too few staff, who are paid too little for physically and emotionally taxing work” and little room for career advancement. Additionally, they acknowledge that while residents’ goals and needs should take priority, often, they are not treated as central considerations.
“COVID-19 has exposed many flaws in our nation’s approach to caring for older adults, including longstanding chronic underfunding, a lack of access to staff and training, and more recently a poorly coordinated response and distribution of PPE, testing and resources needed to protect vulnerable adults,” said commission member and LeadingAge California President and CEO Jeannee Parker Martin. “While the administration has responded with some effort, there is much more to be done to improve the quality and care for the 1.2 million residents in more than 15,000 nursing homes across the country,” she said in a statement. Parker Martin joined Vice President Mike Pence and members of the Commission at the White House on September 18 for a roundtable discussion on strengthening COVID-19 response efforts in skilled nursing and issues impacting the nation’s older adult care system.
Annual spending in 2018 on nursing homes was approximately $170 billion, with Medicare spending approximately $38 billion and Medicaid spending approximately $50 billion, according to the report.
Reporters may want to contact local nursing homes in their area and ask whether these recommendations are realistic, under current budget and staffing parameters. Speak with ombudsman, family council members and (ideally) staff or residents to find out whether, and how, they plan to implement this guidance, or what is needed to do so.