Nursing homes are meant to provide safe, peaceful and comfortable living conditions for our nation’s elderly and disabled. Ideally, these establishments would provide our loved ones with enjoyable places of residence during their later years, when they need help from their community after decades of contribution. Unfortunately, these vital institutions are often forgotten or overlooked by society.
Although we would prefer to take care of our loved ones at home, the demands of modern life make this increasingly difficult. With greater life expectancy, decreasing family size and increasing expectations for all working-age members of the family to earn a living, it is difficult to find time to provide a constant presence for elderly loved ones who need support. Similarly, as large proportions of the elderly population live with functional limitations or chronic conditions, health care expertise is needed to care for these individuals.
Accordingly, nursing homes only stand to become more important in our society. There are two primary uses for these facilities: long-term care for those who have difficulties with activities of daily living — including eating, bathing and continence — as well as short-term assistance for those needing post-acute rehabilitation or conditioning following a major surgery or hospital admission.
Unfortunately, however, nursing homes have been plagued by the suboptimal economic and political realities of America. Care in nursing homes is profoundly expensive, costing hundreds of dollars per day, and although some residents may be covered by Medicaid, this cohort is extremely limited.
For example, in Pennsylvania, residents must be nearly bankrupt to qualify, as they must earn less than $2,382 per month or hold under $2,000 in assets. Additionally, the program only reimburses 70 to 80% of costs, making it difficult for nursing homes to maintain their standard of care or to adapt to major challenges like a pandemic. Compounding this dilemma, around 70% of nursing homes are for-profit, and private equity firms often institute profit-maximizing measures at the expense of residents, with innumerable reports indicating inadequate staffing, poorly-equipped facilities and less-than-ideal daily services.
The COVID-19 pandemic has exposed many of these issues. Early in the pandemic, nursing homes were the primary sources of viral spread in the United States, with unimaginable rates of infection and mortality occurring in these settings. As of January 2022, over 800,000 nursing home residents and 808,000 staff members have contracted the virus, and over 140,000 nursing home residents have died of complications. This accounts for approximately one-third of all U.S. COVID-19 deaths, a staggering number considering that only 1.5 million Americans — less than one percent — live in nursing homes.
A number of unique conditions make nursing homes the ideal hotspots for viral spread: for one, they house patients of advanced age, often with other comorbidities, in very close quarters. These patients often require hands-on care from their caretakers who assist with food, hygiene or daily activities. Furthermore, nursing homes prior to the pandemic suffered from chronic understaffing and a lack of modern renovations. As many as 30% of nursing homes reported nursing and aide shortages, an issue particularly relevant to the pandemic since facilities with better aide-to-resident ratios were able to provide more individualized care and ultimately experienced fewer cases and deaths.
The primary cause of insufficient care in nursing homes is lack of funding. The skilled nursing industry primarily receives financial support through Medicare and Medicaid, and increased funding would likely solve the issue; unfortunately, our health care system is already being stretched to its limits with exorbitant costs. The current payment model disincentives long-term care in two principal ways: Medicare does not fund services beyond 100 days, and Medicaid, which does fund long-term services, does not reimburse as much as Medicare. Moreover, short-term interventions are inherently more lucrative than preventative services. Without a renewed policy focus towards preventative and community-based care, it will not be possible to redirect attention towards nursing facilities to secure adequate funding.
In addition to lacking funding and public attention for both the challenges they face and their integral role in society, the nursing home industry is resistant to change due to opacity of options for consumers. It is difficult for prospective residents and their families to evaluate appropriate options for their care, as they likely have not yet experienced such institutions firsthand and cannot easily access reviews from other “customers.” Without such consumer-oriented data, there is less incentive for competing nursing homes to improve.
The U.S. government developed a five-star rating system in 2008 to provide more insight into nursing home conditions and care standards. Rankings are posted on a website called Care Compare, and since its release, nursing home operators’ annual profits have correlated closely with their “stars” rating on the site. Unfortunately, the data by which these stars are awarded are self-reported by nursing home management and therefore can be easily manipulated.
Blatant misrepresentations have since been uncovered, with some homes simply neglecting to report resident falls and bed sores, underrepresenting rates of antipsychotic medication use and even inflating staffing numbers. One firm found that half of homes underreport bed sores by over 50%, while the inspector general for the Department of Health and Human Services found that only 16% of abuse/neglect-related hospitalizations were reported. Another recent analysis found that residents at five-star homes were just as likely to die from COVID-19 as those at one-star homes. Audits are rare, allowing this issue to persist.
Fortunately, there are various innovative proposals to address this issue. Solutions involve reimagining how our nursing homes are designed and how we view the needs of our elderly population. Creative ideas include creating smaller-scale nursing home setups, instead of large institutions which house hundreds of residents like a college dorm, or increasing government oversight and regulations surrounding staffing and safety requirements.
Reforming the overall model of health care delivery to rely more heavily on in-home care for those who can manage some activities of daily living on their own would also improve both costs and outcomes. In-home care poses numerous advantages; for residents, it means lower overhead costs and a smoother transition, as they do not have to leave behind their communities and homes for a new location. In fact, 75% of nursing home residents would prefer to stay at their own homes. This model can also facilitate more individualized care and permit residents more freedom than a larger institution. Granted, some residents with chronic and degenerative conditions may need more intensive care, but we could certainly transition large portions of our population towards this new model.
A shift in our views is also important. This starts with an increased respect for our older neighbors and an understanding about the immense amounts of waste in health care today. As we live to older and older ages, assisted living will only become more important and money saved from eliminated waste can be redirected towards skilled nursing, where there is a personalized approach to care. With annual nursing home costs nearing hundreds of thousands of dollars for a single resident, there are many areas in which we can improve.
The COVID-19 pandemic’s devastating effects upon our nursing homes has highlighted the vulnerabilities of this sector of our health system. With increased attention to the issues in such a growing and vital part of our society, we have a once-in-a-lifetime opportunity for change. As future physicians, we see an increasing focus on social determinants of health, and a growing proportion of our patients are likely to come from the elderly population.
Much has been said about the nursing home-to-hospital revolving door, and addressing this issue will improve both patient outcomes and reduce system-wide costs. Addressing the challenges which face our nursing homes will undoubtedly improve life for our patients, as management can look to ensure healthier spaces for living, implement more preventative measures and improve adherence to medical providers’ recommendations. Moreover, as we ourselves get older, many of us may at some point interact with the nursing home system and benefit from any progress that is made.
The COVID-19 pandemic posed a tremendous challenge to our community – certainly from a health perspective, but also in nearly every other aspect of daily lives. Our daily routines were upended – from the way we work, play, learn, socialize and travel. Numerous times, the unimaginable happened, and it is safe to say we will never see the world in the same way again. As future physicians, it is important that we recognize the challenges faced by the health care space during the pandemic, and perhaps more importantly, the everlasting transformations that our future medical students, physicians and patients will encounter. This column explores the countless obstacles we overcame and their everlasting effects, along with emerging trends that we will see in health care for the years to come.