A trio of prominent nursing home researchers warned Monday that without new investment in nursing home infrastructure, residents and staff will remain at “substantial risk” for a repeat of the poor outcomes they experienced during COVID.
No one tool or policy change — including a staffing mandate — can prevent another deadly outbreak, they wrote in a new paper published by Health Affairs. Instead, the researchers urged regulators and lawmakers to look beyond superficial, and sometimes wrongly held, beliefs about nursing home circumstances to address failing policy and funding mechanisms.
“People continue to look for easy answers, simple answers and the real solutions are just much harder,” R. Tamara Konetzka (pictured), the Louis Block Professor of Public Health Sciences at the University of Chicago, told McKnight’s Long-Term Care News Monday. “I think the root of the problem is the underlying structure of nursing homes and the fact that we don’t really consider nursing homes part of the healthcare system when we’re thinking about planning for disasters of various types.”
Konetzka, Harvard Medical School’s David Grabowski and Brown University’s Vincent Mor authored “Four years and more than 200,000 deaths later: lessons learned from the COVID-19 pandemic in nursing homes.” The paper reviews four years’ worth of policy successes and failures in American nursing homes. The researchers analyzed existing work to explain the impact of interventions ranging from infection control incentives to vaccinations to increased staffing.
With the exception of the Pharmacy Partnership for Long-Term Care Program and a vaccine mandate, researchers have found that single interventions seldom made a significant dent in COVID-related outcomes.
On pandemic-era staffing shortages that fueled interest in higher staffing requirements, the researchers found “little evidence that low staffing was a primary cause of nursing home resident mortality from COVID-19.” And while the authors embrace more staff as way to promote higher quality care, Konetzka told McKnight’s that a mandate shouldn’t be viewed as a cure-all.
Instead, the greatest predictors of poor COVID outcomes remain prevalence of the virus in the surrounding community and facility size. That, the researchers wrote, is proof that COVID was not a “bad apples” problem, but a systemic one fated to repeat itself without some serious investment at the federal level.
“In the short run, these structural characteristics would be difficult to change, but this may be an opportune time to rethink the physical structure of nursing homes,” they argued. “At this time, much of the nation’s nursing home capital stock is reaching its maximum lifespan and will need to be replaced. In addition to issues such as improving ventilation … the size and room occupancy of nursing homes are changeable in the long run.”
The paper embraced the Green House model and small facilities in general, noting payment reform and a shift in political will would be necessary to usher in broad change that addresses operator concerns about costs.
While some states have begun to experiment with payment incentives for private rooms in nursing homes, Konetzka and her co-authors are advocating for change at the federal level. That kind of investment is critical to making policy stick, Konetzka said.
She would like to see policymakers balance ongoing transparency efforts with an acknowledgment that profit is required to replace aging buildings in the nursing home sector.
She reiterated a 2022 call from the National Academies to move toward a Medicare benefit that works more seamlessly to cover long-term needs across home-based care and nursing home care.
“That would address some of these quality deficits and allow us to do things like consider building smaller nursing homes,” she said. “I would like to see some very fundamental change that sounds maybe pretty pie-in-the-sky … but funding long-term care mostly through the Medicaid system in the long run will never get us to the level of quality we want.”
