Opinion | Nursing homes need fixing. Here’s where to start.

Opinion | Nursing homes need fixing. Here’s where to start.

When the Covid-19 pandemic came to America, nursing homes became “ground zero” for the pandemic. Although less than half of 1 percent of the U.S. population resides in nursing homes, they account for nearly 40 percent of all Covid deaths. Nursing homes are supposed to help residents remain safe and healthy, but the opposite turned out to be the case: When it came to the coronavirus, residents in nursing homes were more vulnerable, not less.

There are many ideas floating around for how to fix nursing homes to make them safer for both long-term residents and short-stay patients going forward. Those suggestions include making facilities smaller, with more private rooms and bathrooms, to keep contagions more contained. Other ideas include partnering with hospitals and improving infection control.

But rebuilding nursing home facilities is an expensive and long-term solution to an immediate crisis. I’ve been studying long-term care settings for many years, and I think there’s a quicker and possibly even more effective approach we can take in the short term to ensure better care for our seniors in the post-Covid era: improve staffing.

It’s no secret that nursing home staff are paid relatively poorly for incredibly demanding work. Certified nurse aides who provide over 90 percent of direct resident care are often paid at or near minimum wage — the same wages as entry-level workers in retail establishments or fast-food chains. Nursing staff are also underpaid; registered nurses and licensed practical nurses who work in nursing homes are often paid below their counterparts who work in hospitals and other health care settings.

What’s more, nursing home staff often lack essential benefits, like health insurance and paid sick leave. That means nursing home workers are incentivized to come to work even when sick — how does that make sense when they are caring for medically vulnerable residents during a pandemic?

Nursing homes are also very hierarchical workplaces with lower-level staff having little autonomy and control in their jobs. Not surprisingly, being undervalued and unempowered makes it hard to recruit and retain individuals to work in nursing homes.

The result is that many facilities around the country often have dangerously low levels of staffing. Additionally, the average U.S. nursing home was recently found to have an annual staff turnover rate of 128 percent. This suggests an average facility’s staff completely changes over the course of a year, and many nursing homes have even higher turnover rates — as much as 300 percent — suggesting the staff changes every four months. If some part of good nursing home quality depends on the relationship between staff and residents, it’s hard to see how those relationships can develop when staff keep changing.

Working conditions have always been challenging in nursing homes, but this has been magnified during the pandemic. Over half a million staff have had confirmed Covid cases, and over 1,500 staff have died from Covid, making nursing home caregiver the most dangerous job in America. Many staff have not received hazard or hero pay or any additional benefits during the pandemic. Many nursing homes have experienced severe staff shortages, with limited access to personal protective equipment and rapid Covid testing. The jobs are so low paid that staff often work in multiple facilities, which contributed to the virus spreading across facilities. Not surprisingly, many nursing home staff report feeling “worn down and stressed out.”

Why do we undervalue staff? Some of this relates to who they are. The majority of the nursing home workforce are certified nursing assistants. These direct care workers are predominantly women, and many are people of color and recent immigrants. Relatively few nursing homes are unionized, and many staff lack the ability to advocate for better pay and benefits.

We also undervalue staff because of how nursing home services are reimbursed. The dominant payer of nursing home services are state Medicaid programs, and Medicaid is not a generous payer. It is not surprising that studies find the most egregious staffing issues occur in high-Medicaid facilities. Yet, staffing issues also occur in a broad range of facilities, even those caring for a greater share of higher-reimbursed Medicare and private-pay residents.

There are a number of things we can do to improve this situation. Here are a few ideas:

Increase minimum staffing levels. One solution would be to increase the number of direct care workers by raising the federal minimum staffing standards in nursing homes. The federal standards are relatively low and have not been updated in over 30 years. Many states set staffing levels above the federal standards and these state policies have generally been found to increase staff.

Increase staff pay and benefits. Another idea is to raise minimum wages to increase nursing home staff pay. Many certified nurse aides would see their hourly wages increase under the $15 minimum wage proposed by the Biden administration. In the absence of a broader minimum wage hike, policymakers could also increase wages specifically for nursing home and other long-term care workers.

Raise Medicaid reimbursement. The elephant in the room is what additional Medicaid or other public funding would be necessary to pay for greater staffing and higher wages. The nursing home industry will inevitably push back against any “unfunded mandates.” The Medicare Payment Advisory Commission has found overall nursing home operating margins are currently thin based on the Medicare cost reports. However, there is quite a bit of variability in profitability across facilities. It is also unclear whether some facilities are accurately reporting their costs. Resident advocates have questioned whether a sufficient amount of existing public nursing home funds are spent on staffing. Thus, higher Medicaid funding will be necessary to improve staffing levels and wages, but it needs to be paired with the next suggestion.

Increase financial transparency. We currently lack transparency in how nursing homes spend public dollars on staffing and other areas. Nursing homes are required to submit Medicare cost reports each year to detail their revenues and spending, but these data are known to be incomplete, especially in the context of increasingly complicated corporate ownership arrangements. A series of financial reporting and oversight steps need to be taken to tighten the requirements for facilities. The bottom line is that regulators need to be able to follow the public’s money and ensure it is being spent on staffing as policymakers intended.

Provide career advancement. Beyond putting more money into wages, policymakers might also consider ways in which they could provide financial support to allow additional education and training to certified nursing assistants and licensed practical nurses seeking upward mobility within a facility. For example, some nursing homes currently have ladder programs that provide nursing assistants with financial support in seeking nursing degrees. These programs could be expanded through direct reimbursement via Medicare and Medicaid.

Create a better work environment. Improving wages and benefits is a necessary but insufficient step towards valuing nursing home caregivers; we also need to begin to value the work these individuals do and the individuals that do it. If you can believe it, this might be harder than increasing staffing standards and wages. Finding additional money is one thing — changing the culture around nursing home staffing is another.

There are nursing home models such as the Green House Project that include “empowered staff” as one of the core tenets of their philosophy. In a traditional nursing home, direct care workers say they have very little control over their job and basically have to do what their superiors tell them to do. In a Green House home, the team of direct care workers have more autonomy including setting their own schedules, finding replacements for absent staff, determining resident assignments, and deciding how the work will be shared.

This leads to more invested and happier staff members, which in turn leads to better care for residents. In fact, one study indicated that Green House nursing homes had markedly lower rates of Covid infections and deaths than traditional nursing homes.

Unfortunately, it’s hard to mandate staff empowerment through policy. But in the short-term, policymakers can improve conditions for staff — and by extension, for residents — through policies that facilitate better wages and benefits for caregivers. In the longer-term, shifting the culture of nursing homes is going to require deeper changes in what we all want from nursing homes for ourselves and those who provide care for us.

The pandemic has shown us the importance of staff, but also the seriousness of the challenges they face in performing a difficult job. In the post-pandemic world, policymakers have the opportunity to adopt a series of measures that will value properly the essential work that these staff do and ensure that our nation’s nursing homes remain safe for older adults in the next crisis.

David C. Grabowski is a professor of health care policy at Harvard Medical School, where he studies long-term care and the economics of aging.

Read more: politico.com

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