Why the US nursing home system is ‘in desperate need of an overhaul’

A recent comprehensive and detailed report from the National Academies of Sciences, Engineering and Medicine called for a revamping of how we care for, finance, and manage nursing homes in the United States, and an overhauling of how employees are hired and trained.

The 600-page report, released on April 6, identified seven major areas requiring transformation to provide high-quality care to all nursing home residents. Strengthening the nursing home workforce, improving emergency preparedness, and increasing the transparency and accountability of nursing homes’ finances, operations and ownership are key goals among the report’s comprehensive recommendations. Efforts will require true collaboration between state and federal authorities, providers, payers and advocates, according to the report’s authors.

The report provides an opportunity for journalists to hold CMS, state officials and owners more accountable for how care is delivered and received for some 1.3 million people in more than 15,000 nursing homes throughout the United States.

“The way in which the United States finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, fragmented and unsustainable,” said Betty Ferrell, Ph.D., director of nursing research and education and professor at City of Hope Medical Center and chair of the Committee on the Quality of Care in Nursing homes, during an online presentation of the committee’s conclusions. (The committee’s work is sponsored in part by the John A. Hartford Foundation, which also sponsors AHCJ’s aging core topic area).

“The committee has delivered a 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,” Ferrell wrote in the report.

As part of that blueprint, the report concluded:

  • How the United States finances, delivers and regulates care in nursing home settings is ineffective, inefficient, fragmented and unsustainable. The current system often fails to provide high-quality care and underappreciates and underprepares nursing home staff for their critical responsibilities.
  • Immediate action is necessary to initiate fundamental change.
  • Stakeholders at all levels need to make clear a shared commitment to the care of nursing home residents.
  • Quality improvement initiatives must be implemented using strategies that do not exacerbate disparities in resource allocation, quality of care, or resident outcomes (including racial and ethnic disparities), which are all too common in nursing home settings.
  • High-quality research is needed to advance the quality of care in nursing homes.
  • The nursing home sector has suffered for many decades from underinvestment in ensuring the quality of care and a lack of accountability for how resources are allocated, including low staff salaries, inadequate training and inadequate support for oversight and regulatory activities.
  • There is a lack of transparency regarding nursing home finances, operations, and ownership. 
  • All relevant federal agencies need to be granted the authority and resources from the U.S. Congress to implement the recommendations of this report.

Addressing shortcomings

“The COVID-19 pandemic ‘lifted the veil,’ revealing and amplifying long-existing shortcomings in nursing home care such as inadequate staffing levels, poor infection control, failures in oversight and regulation, and deficiencies that result in actual patient harm. The pandemic also highlighted nursing home residents’ vulnerability and the pervasive ageism evident in undervaluing the lives of older adults,” the authors wrote.

Despite making up less than one-half of 1% of the U.S. population, as of October 2021, nursing home residents accounted for approximately 19% of all COVID-19 deaths. As of February 2022, more than 149,000 nursing home residents and more than 2,200 staff members had died of COVID-19, according to the report.

Improvement, the committee said, starts with the foundational goal of providing person-centered care that honors residents’ values and preferences. The report calls for the development of quality measures for areas such as palliative care and psychosocial and behavioral health, the development of an overall health equity strategy for nursing homes, and the collection and reporting of information about resident and family satisfaction via  Nursing Home Compare, the Centers for Medicare & Medicaid Services (CMS) website that reports on nursing home quality.

“Critical gaps in the quality of care exists,” said committee member Jasmine Travers, Ph.D., assistant professor of nursing at the New York University Rory Meyers College of Nursing.

To empower, prepare and build a high-quality workforce, the report recommends increasing the number and qualifications of all types of nursing home workers. It also advises the CMS to establish minimum education and national competency standards and to immediately implement requirements for 24/7 registered nursing staff and a full-time social worker in all nursing homes. Facilities should provide ongoing training in diversity and inclusion for all workers and leaders and provide family caregivers with resources and training as needed or desired. Competitive wages and benefits, including health insurance and sick pay, should be offered to help recruit and retain quality staff.

“Nursing home care in the United States is broken,” said committee member David Grabowski, Ph.D., professor of health care policy at Harvard Medical School. “A key barrier to effective nursing home oversight has been a lack of transparency regarding nursing home finances, operations and ownership.”

The report recommends collecting, auditing and making publicly available detailed facility-level data on the finances, operations, and ownership of all nursing homes to boost transparency and accountability. This will provide more comprehensive evaluations of how Medicare and Medicaid payments are spent and the impact of ownership models and spending patterns on the quality of care.

While CMS makes some ownership information available, these data are incomplete, often challenging to use, and do not allow for assessment of quality across facilities owned or operated by the same entity, Grabowski said.

More oversight needed

The report also calls for CMS and states to improve oversight of nursing homes to avoid a repeat of the failures that occurred during the COVID-19 pandemic. It recommends that federal and oversight agencies impose enforcement actions such as denial of new or renewed licensure on owners with a pattern of poor-quality care across facilities. As part of its efforts to strengthen oversight of nursing homes, CMS should also ensure state survey agencies have the capacity, organizational structure, and resources for their responsibilities, including monitoring nursing homes, investigating complaints and enforcing regulations.

Other goals the report addresses include the need for a more robust financing system, including an analysis of Medicare and Medicaid payments; designing a more effective and responsive system of quality assurance; expanding and enhancing quality measurement and continuous quality improvement; and adopting health information technology in all nursing homes.

“This report is a piercing wake-up call for policymakers. Decades of underfunding have left America’s nursing home system in desperate need of an overhaul,” Katie Smith Sloan, president, and CEO, LeadingAge — the association of nonprofit providers of aging services, including nursing homes, said in a statement. “How our nation supports the system that cares for older adults is a reflection of our values. At the end of the day, this is about equity—in access, in quality and in professionalizing our direct care workforce.”

Some recommendations can be fully implemented immediately, while others require planning, coordination, and larger-scale effort. Each of the components of the committee’s recommendations were categorized into an estimated implementation timeline

“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,” Ferrell wrote.


Leave a Reply