Both operator and consumer stakeholders need to think outside the box and look beyond their differences to make a real difference in how facilities operate and address quality concerns, a high-level panel of experts on care home staff and residents’ experiences agreed on Monday.
The greatest challenge, however, may be to make policymakers at all levels aware of the role nursing homes play in caring for so many aging Americans.
“While approximately 1.2 million Americans live in nursing homes today, nursing homes must be important to all of us,” said Terry Fulmer, president of the John A. Hartford Foundation, which co-hosted the briefing with Health matters.
“These are homes, homes for the elderly and people with disabilities, who have the most complex needs and are the most vulnerable,” Fulmer added. “(Nursing homes) are an important part of our health care system, albeit an often ignored part.”
Other panelists, R. Tamara Konetzka, PhD, of the University of Chicago; David Grabowski, PhD, of Harvard Medical School; and John Bowblis, PhD, of Miami University, emphasized how longstanding concerns about nursing home practices, payment, and performance have been amplified by the pandemic. And each of them offered research-backed options that could help implement calls for improvements made in the National Academies’ landmark 2022 report on the National Imperative to Improve Nursing Home Quality.
But while all expressed support for more staff, they also qualified their comments in light of current labor market realities, political obstacles and the cost of hiring new staff in light of the nationwide nursing shortage.
“The most important factor in promoting quality care in nursing homes is the people who work in those buildings, the staff,” said Grabowski (pictured), who pointed to previous work on immigrants in the sector. “Today, foreign-born workers are more important than ever. … They are not displacing the jobs of native-born workers. They are complementing the workforce.”
Call to increase refunds, immigration
He called for more supportive and creative immigration policies that could help the sector recruit less-skilled workers through special, expanded visa programs, rather than targeting those who happen to come through asylum or family reunification.
“Often people look at immigration as a ‘replacement’ or a replacement for other policies we could implement,” Grabowski said. “I firmly believe that immigration needs to complement other approaches to expanding the workforce (such as) better wages and benefits, minimum standards for staffing … We need to increase reimbursement rates and make sure that these funds go directly to the health care workers.”
Kezia Scales of the labor advocacy group PHI said it is critical that immigration reform not only offers immigrants jobs in nursing homes, but that policymakers and providers support the foreign-born workers they hire through integration efforts, workplace improvements, career opportunities and a path to citizenship to make the jobs attractive and retain them.
She also argued for staffing improvements in response to Bowblis’ “appalling” research, which found that staffing levels at temporary work agencies remained high well into the pandemic – with large numbers of providers moving from occasional, short-term use to near-daily reliance. Bowblis also linked the work to previous findings on care continuity and staffing stability as key factors in the quality of care; temporary work agencies undermine both.
“We need to use all available policy and practice tools to improve non-contract nursing home jobs so that job seekers and existing workers can choose and keep these jobs,” she said. “We really need to fund and conduct more research to better understand what is happening with the trend toward contract care in nursing homes… so we can develop the right policies to slow and even reverse it.”
The use of agencies remains a cause for concern
While some recent data suggests nursing homes have relied less on and spent less money on agency care over the past year, Bowblis warned that the federal government’s new staffing requirement could force providers to hire less-than-ideal staff.
“Yes, increased staffing is an important consideration, but I think we need to think about the composition of the staff,” he said. “If the agency staff we deploy to meet those needs are not motivated and are not caring for the residents properly, we may not achieve what we want, which is to have more staff that are truly caring for the residents and doing what is best for them.”
Grabowski and Konetzka also pointed out that there remains a stalemate in quality improvement, partly due to disagreements about whether the sector is draining too much money from facilities.
Grabowski called for more transparency to help information sharing. Konetzka said she wants to make it clear to everyone involved that there could be multiple scenarios in the nursing industry. For example, complex ownership structures could make it difficult to see where government funds are going. But nursing homes could also be largely underfunded by a system that relies on Medicaid.
CMS defends, plans
Panelists also discussed spending on oversight and whether it really supports quality goals.
Jean Moody Williams of the Center for Medicare & Medicaid Services continued to defend the staffing policy and lamented years of stagnant funding for national survey offices, but she also promised that the agency plans to release a new study “soon” showing that the agency’s targeted education and support services during the early pandemic helped reduce COVID cases by 25% among residents and 19% among staff, compared to facilities that did not implement any intervention.
“I think we will continue to learn for many years to come,” she said, “but the important point is that we translate these learnings into action through both public and private efforts to provide the best possible experience for residents, families and caregivers.”
