July 23, 2020

It's Time to Defund Nursing Homes

By Charles Sabatino*
Thousands of residents died in nursing homes from COVID-19

Thousands of residents died in nursing homes from COVID-19

Just as the Defund Police movement underscores the institutional racism that cries out for fundamental change, the COVID-19 pandemic ravaging nursing home residents underscores a deep-seated ageism inherent in our institutional model of nursing home care. It is time to defund the institutional model and replace it with a radically different model.   

Today’s typical nursing home has never come close to meeting the public’s desire for humane and dignified long-term care. Warehousing large numbers of frail elders in hospital-like buildings with residents in double or triple rooms, and staff turnover as high as 100 percent, unavoidably creates a high risk for resident safety and compromises quality of care.  Even before the pandemic, 82 percent of all nursing homes had infection prevention and control deficiencies cited in one or more years from 2013-2017, according to the U.S. Government Accountability Office. Forty-eight percent had such a deficiency cited in multiple years.

Despite the $90 million paid annually by Medicare and Medicaid to nursing homes, and exacting regulatory requirements addressing quality of care and quality of life for the nation’s 1.3 million nursing home residents, we as a society have failed to keep frail elders safe – let alone in an environment that any older adult looks forward to. Data from the Centers for Medicare and Medicaid Services indicate that, as of the end of May, over 32,000 nursing home residents had died in the 88 percent of nursing homes that reported data. Other analyses have reported nursing home resident and staff deaths represent 40 percent of the nation’s COVID-19 deaths, and in some local areas, as high as 75 percent.

As a result, multiple recommendations for change have gained attention, such as ensuring adequate personal protective equipment; disaster plans that facilitate quarantining; more and better trained staff; and heightened monitoring and oversight of care. Let’s be clear: These measures do little more than rearrange the deck chairs in a failing system. The COVID-19 pandemic is a 9/11 moment for nursing home care and a test of our ability to reimagine nursing home care that puts the “home” into nursing homes. 

As the largest payor for nursing home care, Medicare and Medicaid hold the key. Now is the time to change facility requirements to gradually limit participation in the program only to facilities that provide the following:

  • Small home-like facilities
  • Single rooms and bathrooms
  • A flattened, more flexible staff hierarchy with cross-trained staff
  • A culture focused on residents’ goals, interests and preferences first

Fortunately, there is already a model for this kind of facility: the Green House Project, represented by 300 facilities nationally, each with 10 or 12 residents who have single rooms and private baths. The facilities are designed around a living room with fireplace and an open kitchen where meals are prepared and shared. The cross-trained staff, backed by nurses and doctors, engage personally with residents, serving as nurse aides, cooks, cleaners, and participants in meals and social activities. Not surprisingly, staff turnover is far below that of traditional nursing homes.

Of most importance to policy makers, Green House Project homes have a strong evidence base showing high resident, family, and worker satisfaction; better quality of care and quality of life; costs comparable to traditional nursing homes; and in the midst of the current pandemic, a much greater ability to prevent and contain illness. Data collected in ongoing research has revealed only 32 confirmed resident cases and one resident death as of June 30 in a sample of 2,384 residents in 229 Green House homes providing skilled nursing.

As long as the nursing home industry can rely on the flow of federal money for the current model of care, it has no financial incentive to change, not even after the coronavirus catastrophe. Change that flow, and a major cultural change in long-term care will follow.

* Charles Sabatino is the Director of the American Bar Association Commission on Law and Aging. The views contained in this article represent his opinions and should not be construed to be those of either the American Bar Association or the Commission on Law and Aging unless adopted pursuant to the bylaws of the Association.