NASEM Nursing Homes Report Could Spark Debate

The NASEM report on nursing homes could be the centerpiece of a far-reaching public information effort aimed to get LTSS issues into political campaigns.

Soon, the National Academies of Sciences, Engineering, and Medicine (NASEM) will issue their report on the future of nursing homes. If advocates for long-term care reforms sit back and observe, this is likely to join a lot of other responsible, thoughtful, evidence-based writings on shelves in libraries.  But it’s possible that we could make it one of the centerpieces of a broad-reaching public information effort aimed at making long-term supportive services (LTSS) a serious part of political campaigns upcoming.

Sure – this report will focus only on nursing homes, but that can be a very useful fulcrum for examining the overall arrangements for supporting how most of us will live with serious disability in old age.  We could take the recent article by McGarry and Grabowski (“Nursing Homes and COVID-19: A Crisis on Top of a Crisis”) as indicative of the sort of recommendations likely to come with the Academies report.  That paper listed ten reforms:

  1. Realigning Medicare and Medicaid (to make all payments equal the costs of care)
  2. Higher wages for direct care staff
  3. Minimum staffing requirements
  4. Increase financial and ownership transparency
  5. Regulatory reform (to focus on major risks and provide collaborative help to improve)
  6. Increase quality transparency (to include what residents and families care most about)
  7. Increase presence of clinicians onsite
  8. Alternative models of nursing home care (small homes)
  9. Increase use of home- and community-based services (HCBS)
  10. Long-term care financing (perhaps expanding Medicare or creating a new federal LTC benefit)

Let’s assume for the moment that the National Academy report makes basically these recommendations. I’d contend that they are basically good ideas. Two questions arise: (1) How will they get effectuated? And (2) What more needs to be on the policy agenda? 

Taking the second question first – one very important element that is missing is the context of long-term care – the community’s housing possibilities, the availability of direct care workers for home care, the flexibility of local employers to enable family caregiving, and so on.  Nursing home utilization and patterns of practice are profoundly entwined with the rest of the local care arrangements.  The report should call for reforms to extend beyond merely advocating for HCBS and should have taken into account the rest of the arrangements that affect long-term care. I’d suggest advocating for a substantial CMS demo on excellence in moderate-sized geographic populations. Let’s learn what can really work well for all of eldercare.

Now, the first question – what would make the public and its leadership take notice?  The proclivity of Americans to dodge questions of disability and old age is all too obvious.  Perhaps some of this head-in-the-sand behavior arises from a sense that there’s nothing to do – long-term care is tragic and troubling but also overwhelming.  To counter this sentiment, we need concrete actionable steps.  We need to get behind some specific fixes that are both understandable and motivating. Try these slogans:

“Make it possible to pay for your own old age” (and tie that to financing changes);

“A home for every elder” (and tie that to making homelessness in old age unacceptable);

“Long Term Care = LTC, Lots of Tender Caring” (and hook that to staffing levels);

“Fair Wage for Hard Work” (tied to a living wage for direct care workers).

How about a bumper sticker? “LT$$ – financing for our old age.” The WISH Act (HR 4289) could help with financing.

I’m sure readers can suggest more clever tag lines, but we need to pull them together and slam the social media with messages that push policy agendas and call on political leaders to take stands. 

Could you be ready to help make a Twitter and Facebook firestorm when the National Academy report comes out? And to follow up with emails to Congress and to heads of influential organizations?

Author: Dr. Joanne Lynn

Dr. Lynn is a geriatrician and hospice physician doing advocacy and research to improve eldercare. She encourages better financing models for long-term care and demonstration projects to improve eldercare in communities. Dr. Lynn has published over 300 peer-reviewed medical research and policy articles.

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