If you had to give the nation’s nursing homes a letter grade for quality, what would it be?
Experts tend to sigh at this question and point out, correctly, that the country’s 15,600 facilities are vastly different — rural and urban, for-profit and nonprofit and government-run, home to the reasonably healthy and the extremely sick, high-quality operations and appalling ones. Assigning grades can be folly.
But when prodded, they come up with decidedly middling assessments. Dr. Cheryl Phillips, head of public policy for LeadingAge, which represents 2,200 nonprofit nursing homes: C-minus.
Nicholas Castle, a health policy researcher at the University of Pittsburgh: B-minus.
Robyn Grant, public policy director at the National Consumer Voice for Quality Long-Term Care, a leading advocacy group: No grade. “Far too many have a long way to go to give residents the quality of care and quality of life they deserve.”
I asked because the Centers for Medicare and Medicaid Services last fall issued a broad revision of nursing home regulations; the first batch took effect in late November, with the rest to be phased in this year and in 2019.
“These are the first comprehensive updates to long-term care requirements since 1991,” said Dr. Kate Goodrich, the centers’ chief medical officer. They emerged from a four-year process involving many meetings and almost 10,000 comments from interested parties.
Will the new requirements help improve care for the country’s 1.4 million nursing home residents — perhaps raise the report card grade to a solid B? “From our perspective, it’s a mixed bag,” Grant said.
Residents and families will most likely appreciate some of these changes once they are in place. But the regulations disappointed nursing associations and many advocates by declining to set minimum staffing standards. And one key provision has been stopped in its tracks by a lawsuit.
A look at some particulars:
• The regulations strengthen residents’ control over certain decisions important to their daily lives. For example, the rules allow people to receive any visitor they choose (not just relatives) whenever they choose, without restricted hours, as long as visitors don’t disturb other residents.
Just having family members around in the evening, when homes have fewer staff members, might improve attention and care, Castle pointed out.
The requirements also allow residents to choose their roommates when both parties agree, making it easier for friends, siblings or same-sex couples to share living quarters. And they require facilities to make meals and snacks available when residents want to eat, not only at predetermined mealtimes.
“Overall, we are really pleased with the focus on person-centered care, trying to transform the nursing home environment,” Phillips said.
• For the first time, nursing homes must take “reasonable care” of residents’ personal belongings and can’t shrug off responsibility for theft or loss by requiring residents to sign waivers.
Moving into a nursing home requires giving up so many possessions that “losing something can be devastating” — especially when eyeglasses, hearing aids or dentures go missing.
• The regulations call for expanded staff training in preventing elder abuse and in caring for patients with dementia. Phillips calls the latter critically important; most residents have moderate or severe dementia, Medicare statistics show. The rule also requires a nursing home to designate an infection-control officer and to establish a system to monitor antibiotic use.
• Long-term-care ombudsmen report frequent complaints of “dumping”: A nursing home sends a resident, often someone whose dementia causes problematic behavior, to a hospital. Then, after she is discharged, the home won’t readmit her. “Once they’re out the door, it’s a lot easier to just evict someone,” said Grant.
The existing regulations provide a lot of protection against being bounced from nursing homes; the new rule extends those protections to someone who’s been hospitalized but intends to return. She can appeal, and the facility cannot transfer her while she does.
But one major change, a ban on the binding arbitration agreements that nursing homes frequently require at admission — before any dispute arises — has stalled.
The American Health Care Association, which represents most for-profit nursing homes — 70 percent of nursing homes in the United States are for-profit — filed suit to stop the change. In November, a federal court in Mississippi granted a preliminary injunction.
Giving residents and families the right to take nursing homes to court could bring far-reaching results, Grant said. Arbitration proceedings typically remain confidential, and monetary awards can be modest.
“It’s all behind closed doors,” Grant said. “When you have a public lawsuit, that’s an amount of money that gets attention from owners and operators and serves as a deterrent” to substandard care.
Medicare has appealed, but a final court disposition could be months or years away. “This may be one area where CMS says, ‘We tried it and it didn’t work,’” Phillips said. LeadingAge takes the position that arbitration should be optional but not outlawed.
The government also declined to incorporate specific staff ratios or minimum hours of care in the new regulations, or to require nursing homes to have registered nurses on site around the clock. (Current rules require RNs only for eight hours.)
Instead, homes must develop assessments of their resources and residents’ needs and hire accordingly. Federal regulators feared that some homes, particularly in rural areas, might find higher staff requirements unnecessary and impossible to reach, and close down rather than face violations and fines.
Advocates are fuming, however, because better staffing has been shown to improve quality of care. Without standards, “it’s completely left to the nursing homes, and they’re not going to change because there’s no incentive to,” said Charlene Harrington, a longtime nursing home researcher at the University of California, San Francisco.
“They can cut staff, keep their wages low and pocket the profits,” she said.
As with any regulation, much depends on implementation and enforcement. Medicare will not issue guidance — the details on exactly how nursing homes must comply — until summer.
And some obvious upgrades lie beyond the scope of such rules, Castle pointed out.
Paying nursing aides more helps to reduce staff turnover, he said, as does “consistent assignment” — having aides care for and develop relationships with the same patients each day.
“If you really want to improve nursing homes, you should pay more for Medicaid,” Castle added. The federal and state program underwrites most long-stay nursing home care, and it is chronically underfunded. “What do you do with $98 a day to care for a resident?”
But Washington doesn’t seem to be in a let’s-pay-more mood. In fact, “we’re wondering and worrying whether these new regulations will be repealed” by the Republican Congress, Grant said.
For now, though, they are the law. Families and residents who want to know more can wade through hundreds of pages in the Federal Register (I don’t recommend it) or turn to summaries compiled by consumer groups.
Better yet, they can contact local or state long-term-care ombudsmen to learn how the changes apply to them. Consumer Voice provides a locater at theconsumervoice.org.