Five Federal Policies We Need Now to Improve Nursing Homes and Respond to Covid-19

Anne Montgomery and Sarah Slocum, co-directors of Altarum’s Program to Improve Eldercare, share five federal policies that should be enacted to ensure nursing home residents receive adequate protection from the novel coronavirus and future pandemics.

The Centers for Medicare & Medicaid Services recently announced plans to enhance enforcement for nursing homes with violations of longstanding infection control practices. That is a positive development, and other recently proposed legislation, including S. 3768, the Nursing Home COVID 19 Protection and Prevention Act, would also improve safety of nursing homes by addressing many of the following policy recommendations.

1. Require nursing facilities to provide all staff with personal protective equipment (PPE), testing on a regular basis for all staff working with residents, and stepped up training for all direct care staff.

2. Encourage nursing facilities to offer advanced care planning to all residents through the required comprehensive care planning processes. This is a low-burden way to integrate advanced care planning into existing nursing home procedures.

3. Create career pathways for Certified Nursing Assistants (CNA). These career advancements would include creation of advanced CNA certifications, such as Covid-19 Specialized CNA, CNA Trainers, CNA Mentors, and other advanced roles.
   
   The certifications could be designed to pay higher wages that are set as percentage increases linked to completion of specific training and gained competencies. For example, a Covid-19 Specialized CNA could be paid 20 percent more than the current average CNA pay rate. The Secretary of Health and Human Services could urge nursing homes to make career advancement a major component of hiring for all frontline positions; and reporting on frontline staff wages and wage increases could be made part of PBJ (Payroll-Based Journal) reporting.
   
   In addition to paying for PPE and expenses directly related to resident needs, any additional reimbursements that policymakers contemplate providing to skilled nursing facilities (reimbursed by Medicare) and/or to states for nursing facilities reimbursed under Medicaid to assist them with weathering the Covid-19 crisis should be for these purposes. Reporting and auditing of the additional funds should be required. Medicaid rate increases could be paid with a special increase in the federal share for states that implement the career advancement components.

4. Authorize a National Academy of Medicine study of the disproportionate impact of Covid-19 on nursing homes that serve significant numbers of residents of color. This could examine longstanding challenges in some parts of the nursing home industry, which include:

• diverting funds meant for resident care and staff support to other areas, leading to lower quality of care and financial instability of the institution;
• tolerating inadequate numbers of direct care staff;
• failing to insist on quality, up-to-date training and re-training in person-centered care; and
• understanding the physical and mental health toll endured by vulnerable elders of color due to a lifetime of poverty and poor access to health care.

Sign up for our monthly newsletter

Be among the first to receive new research and insights from Altarum on eldercare.

These factors are compounded by the fact that many homes with large proportions of elderly residents of color are heavily dependent on Medicaid as their main revenue source, and in many states, Medicaid nursing home reimbursement is low. Study panelists should reflect the expertise and views of medical and administrative staff, representatives of frontline direct care staff, policy experts, family members representing the interests of their vulnerable elders, advocates and residents living in nursing homes.

5. Develop a federal “Early Warning System” to identify and address problems in nursing facilities that need extra attention. Establish an interagency task force composed of the Centers for Medicare & Medicaid Services, the Department of Health and Human Services Office of Inspector General, Centers for Disease Control and Prevention, and the Department of Justice that meets and reports to Congress quarterly. Its chief responsibilities would include:

• Analyzing data on nursing-home owners and other individuals and parties that form the Provider Enrollment, Chain, and Ownership System (PECOS); information about staffing that is available in the Payroll-Based Journal database; and information from the survey and certification inspection program. Inspectors in the survey and certification program are currently tasked with focusing mainly on infection control, but will resume broader duties later in 2020.

• Identifying patterns of poor quality of care and stress (including financial distress) in individual facilities, chains, and groups of homes that are linked by ownership or financial investment. Information about these patterns would be used to make a wide variety of recommendations, including stepped up oversight and coordinated enforcement as well as coordination with federal and state emergency management systems to activate resources when facilities are not able to assure resident safety.

• Analyzing data on infection and death rates associated with Covid-19 in nursing facilities, from the Centers for Disease Control as well as data on infection and death rates in other types of LTC residential facilities, as it becomes available.

Nursing homes can take independent action to improve care, including engaging in culture-change initiatives to transition from a top-down institutional model of care to one that is person-centered, which Anne Montgomery recently wrote about in Aging Today.

Read more about how Altarum is helping states and communities rethink eldercare services by improving the quality of long-term care services and support.