2022 NASEM Quality of Nursing Home Report: Moving Recommendations to Action

The way the United States finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, inequitable, fragmented, and unsustainable. The failings of the US healthcare system regarding nursing homes are reflected in poor resident outcomes, substantial government spending, pervasive inequities, and an underpaid and demoralized workforce (Konetzka, Yan, & Werner, 2021; Sloane et al., 2021; Travers et al., 2020; Travers et al., 2021; Yang, Yong, & Scott, 2022). Between the years of 2013 and 2017, 82% of nursing homes were cited for an infection prevention and control deficiency (U.S. Government Accountability Office, 2020). Consequently, it is no surprise residents and those working in the nursing home sector suffered greatly under the weight of the coronavirus disease 2019 (COVID-19) pandemic. Images of isolated residents languishing day after day, reports of infections fomented by lack of personal protective equipment, the deaths of over 150,000 residents, and stories of underpaid staff working in unsafe conditions with little respite, recognition, or support, have plagued news feeds for over 2 years. And yet, many underlying problems related to how the United States finances and regulates nursing home care have existed for decades in nursing homes without timely and critical legislative intervention. Four reports produced by the Institute of Medicine, now the National Academies of Sciences, Engineering, and Medicine (NASEM), proposed solutions for improving care delivery in nursing homes (Institute of Medicine Committee on Nursing Home Regulation, 1986; Institute of Medicine Committee on Improving Quality in Long-Term Care et al., 2001; Institute of Medicine Committee on the Adequacy of Nursing Staff in Hospitals and Nursing Homes et al., 1996; Institute of Medicine Committee on the Future Health Care Workforce for Older Americans, 2008). Some led to significant changes, such as the passage of OBRA 1987, and promulgation of new standards; however, none have resulted in change that eradicated these fundamental problems. Immediate action to initiate meaningful change is necessary. In 2020, NASEM convened a 17-member committee that represented policy, practice, and research perspectives to examine how our nation delivers, regulates, finances, and measures the quality of nursing home care, including the long-standing challenges brought to light by the COVID-19 pandemic. Different from earlier committees, the committee was tasked with making bold but actionable recommendations for effecting change in nursing homes. The committee articulated a vision in which nursing home residents receive care in a safe environment that honors their values and preferences, meets goals of care, promotes equity, and assesses the benefits and risks of care and treatments and detailed seven goals and related recommendations in a report titled The National Imperative to Improve Nursing Home Quality, released April 6, 2022 (https://nap.nationalacademies.org/catalog/26526/the-national-imperative-to-improve-nursing-home-quality-honoring-our). The goals spanned several areas: care delivery, workforce, transparency and accountability, financing, quality assurance, quality measurement, and technology. The committee specified that these goals could be advanced through recommendations such as identifying and fulfilling care preferences for all residents, improving working conditions across the nursing home workforce, increasing access to quality care through a federal long-term care benefit, improving quality metrics such as developing a health equity measure, and prioritizing models that reduce disparities including diversity, equity, and inclusion training. Importantly, the committee intentionally threaded equity throughout the report and recommendations. This issue presents five articles co-authored by seven committee members that focus on specific recommendations of the NASEM report and how relevant stakeholders might move those recommendations into action. Two editorials are also included in this issue. This editorial presents the issues, the articles, and what is to come, and a second editorial summarizes the strengths of the report and the gaps. Following, we summarize all six of these contributions. The care needs of residents are both complex and dynamic; therefore, nursing homes must have a well-prepared workforce with sufficient education and training. Mueller and Travers (2023) provide additional direction and considerations for moving the committee's recommendations focused on the educational and training needs of this workforce forward. The authors highlight the need for minimum degree and certification requirements for nurses, social workers, physicians and other workers, greater hours in training for certified nursing assistants, geriatric-specific content in curricula, and experiential learning for all nursing home staff. Improving nursing home quality of care has been a perennial goal over the past few decades. However, inadequate investment, policy development, and enforcement have left us with a system that lacks the capacity to deliver high-quality care congruent with resident preferences. The preeminent goal of the NASEM report is to promote care models that can deliver comprehensive, person-centered, and equitable care to residents. In their article, Rantz and Ersek (2023) delineate several pragmatic approaches that would encourage the successful development, implementation, and maintenance of these care models. Several Federal policies focus on improving the working conditions for certifiede nursing assistants (CNAs), but legislative gaps remain. McMullen and Travers (2023) performed an exploratory review of existing federal policies to identify how these policies align with the Committee's recommendations specific to CNAs. The authors also highlight the gaps in these policies and offer suggestions pertaining to the development of actionable and salient federal policies and rules. Poor care exists in too many nursing homes, despite significant federal and state expenditures. Grabowski, Chen, and Saliba (2023) highlight the need for alternative payment models that incentivize safety and quality in this setting. They focus on payment demonstrations and policies attempted in the past, lessons from those efforts, and challenges that should be addressed in future demonstration efforts. Health information technology (HIT) is a fundamental tool to optimize health care delivery. Several landmark federal policies have facilitated the rapid adoption of HIT into the US healthcare system. Alexander and McMullen (2023) describe how nursing homes have been categorically excluded from this wave of federal support, resulting in a technology infrastructure that lags decades behind those of hospitals and clinics—further driving disparities in health outcomes for this resident population. Moving forward, they underscore the importance of financial support from state and federal governments to promote the successful implementation of HIT into nursing homes. As mentioned previously, this supplement also includes a second editorial co-authored by Degenholtz et al. (2023) that focuses not only on the NASEM report but beyond. This editorial specifically sheds light on the strengths of the report along with what is missing from the report that still needs to be addressed. In July 2022, the Moving Forward Nursing Home Quality Coalition convened to take action now on issues raised in the NASEM report that can be addressed immediately or in the near future. The Moving Forward Coalition is different from other groups and previous efforts in that it has brought together many different types of organizations and government agencies and is focused on specific actions that will be tested now. Funded by the John A. Hartford Foundation and chaired by Dr. Alice Bonner, the 2-year initiative has created a sustainable coalition that will continue its work with nursing homes and communities beyond 2024. The coalition includes seven members from the original NASEM Report Committee along with other interested organizations and stakeholders, such as policymakers, nursing home residents, advocates, aging experts, professional associations, and nursing home staff members. Over the last several months, seven committees have worked together to design and test action plans based on the seven goal categories outlined in the NASEM report. These committees have prioritized one to two recommendations under each of those goals and are developing next steps and best practices to realize them. Some of those action plans are or will be ready to test in the next few months. In addition, The Moving Forward Coalition Chair, along with two members who served on the NASEM committee and now on a Moving Forward Coalition committee, presented testimony on September 21st, 2022, to the US House Select Subcommittee on the Coronavirus Crisis, urging Congress to take action to improve nursing home quality now (https://coronavirus.house.gov/subcommittee-activity/hearings/hearing-examining-long-term-care-america-impact-coronavirus-nursing). Coalition committee co-chairs and members have engaged Centers for Medicare and Medicaid Services (CMS) and other federal agencies in conversations about how to work collaboratively to test and implement action plans starting in this year, 2023. It is important to note that the NASEM report is a public document that anyone may act on through next steps. There is not a requirement for Congress to act, although many of the recommendations do suggest that Congress could require that CMS or other federal agencies take specific next steps. Committed to an ethic of inclusivity and equity, Moving Forward continues to seek and engage interested participants to join in leading this national effort to improve nursing home quality. Specifically, the Coalition will work closely with nursing home partners, advocates, and policymakers to test and implement action plans developed over the first year of the initiative. The Coalition strives to make change in the short term, while building a path toward sustainable and long-term action. Each of us deserves age-friendly care in a safe, high-quality nursing home, and individuals that work in nursing homes want the ability to promote independence and to support what matters to older adults. The Moving Forward Coalition will be successful if organizations, representatives of both major political parties, and relevant stakeholders continue to convene, listen to one another, and find a common path forward through action plan implementation. For more information on how you can get involved with Moving Forward, please contact Isaac Longobardi at [email protected].org. Additional resources, including highlights of the report and policy briefs, can be found on the NASEM website (https://nap.nationalacademies.org/catalog/26526/the-national-imperative-to-improve-nursing-home-quality-honoring-our). Useful resources within the report include recommendations targeting responsible partners (https://nap.nationalacademies.org/read/26526/chapter/16) and a timeline (https://nap.nationalacademies.org/read/26526/chapter/17) of when the committee believes each recommendation may be able to be implemented. Information on the Moving Forward Nursing Home Quality Coalition may be found at https://movingforwardcoalition.org/. We know what needs to be done. It is time to come together and make it happen. This supplement is sponsored by The John A. Hartford Foundation. None. J. Travers served as the contact editor for the supplement, in which this article is included, but was not involved in the review or decision for the article.