Why Nursing Homes Need A Total Redesign

 by Charles P. Sabatino

The COVID-19 pandemic, more than any other event in our time, has focused a sharp light on the deficient state of nursing home care in our country. A multitude of interwoven, dynamic factors determine quality, but the physical environment creates the concrete template that materially supports or impedes all other factors affecting quality. You would not build a baseball field in the design of a golf course; and you would not build a home in the design of a hospital. The traditional institutional nursing facility design today does not support either quality of care or quality of life. The “home” is missing in most nursing homes. It is time to fundamentally redesign and reimagine nursing homes.

The Current State Of Affairs

During the pandemic, nursing home residents suffered disproportionately high rates of COVID-19 cases, hospitalizations, and deaths compared to the general population. Despite accounting for less than 1 percent of the US population, long-term care residents and staff accounted for at least 23 percent of all COVID-19 deaths in the US as of January 30, 2022.

Even before the pandemic, infection control in nursing homes had been a perennial problem. The Government Accountability Office found that, from 2013 to 2017, 82 percent of all inspected nursing homes had infection prevention and control deficiencies, and about half experienced persistent problems and were cited for multiple years.

The more than 15,000 nursing homes in the US are mostly large facilities. According to the National Center for Health Statistics, they average 106 beds each and house some 1.5 million residents. The nursing home industry mushroomed after the passage of Medicare and Medicaid in 1965 and physically borrowed many institutional design features adapted from hospitals constructed in the same era, including features such as “long corridors, large activity and dining spaces, shared rooms and bathrooms, and lack of ready access to outdoors.”

Most nursing home residents are made to live in shared rooms, usually with one other person but as many as three, as permitted by Medicare and Medicaid regulations. Shared rooms have almost disappeared from modern hospitals, yet they remain the norm in traditional nursing homes, depriving most residents of lifelong patterns of privacy and control over environment and personal association.

Most Americans do not ever want to move to a nursing home. A John A. Hartford Foundation post-COVID-19 survey of older adults found that 71 percent of older adults are “unwilling to live in a nursing home in the future,” and nearly 90 percent said that “changes are needed to make nursing home appealing to them.” Society’s tolerance of nursing homes appears to be based on the mistaken assumption that there is just no other way to care for many persons needing 24/7 care or supervision.

Direct care workers demonstrate an aversion to working in traditional nursing homes. A startling study published in Health Affairs reported that, between 2017 and 2018, the overall nursing home workforce had a mean turnover rate of 128.0 percent, with 140.7 percent mean turnover for registered nurses, 129.1 percent for certified nursing assistants, and 114.1 percent for licensed practical nurses. A recent American Health Care Association Survey found that 98 percent of nursing homes are experiencing difficulty hiring staff.

The kind of long-term institutional environment to which we relegate our most chronically ill elders is a model that we have almost entirely eliminated for persons with mental illness and developmental disabilities and for children in foster care, but we continue to tolerate it for older persons. The expansion of home- and community-based care has been a welcome alternative but will not work for everyone needing long-term care. Society cannot afford to provide one-on-one care to all individuals needing 24/7 care, so group care in some kind of housing will always be needed—but it need not be of institutional design. The lack of will to overcome the institutional inertia of the status quo has been our greatest barrier to change. There is a better alternative.

An Alternative To Traditional Nursing Homes

Small, household models of skilled nursing care are not new, but they have been largely overlooked until the COVID-19 pandemic, during which they fared far better than traditional nursing homes. At the same time, a growing body of research shows a multitude of quality advantages over traditional nursing homes.

The data below highlights the Green House® Project homes, because the research on this model is the most robust. Green House homes feature not only small facility size and private rooms, but also empowered cross-trained staff and welcoming, home-like communal spaces. There are about 300 Green House Homes in 32 states, with 87 percent of them licensed as skilled nursing homes. They are home to a total of more than 3,200 residents and fare better than traditional nursing home on multiple measures. For example:

Mortality. Comparing Green House data with Centers for Medicare and Medicaid Services (CMS) data, Green House homes produced far more favorable outcomes during the first two years of the pandemic. In 2020, Green House homes experienced 25.0 deaths per 1,000 residents versus 86.8 for traditional nursing homes. In 2021, Green House homes experienced 41.3 deaths per 1,000 residents versus 122.4 for traditional nursing homes.

Staff Turnover And Satisfaction. Year-by-year comparable data are not available before 2022, but when comparing Green House homes data from 2020 with available data for traditional nursing homes from 2017 to 2018, Green House homes reported substantially lower turnover rates:

• Certified nursing assistants (CNAs) (who are cross-trained as universal caregivers in the Green House model): 33.5 percent turnover at Green House homes versus 129.1 percent in traditional nursing homes;
• Licensed practical nurses: 41.6 percent turnover in Green House homes versus 114.1 percent in traditional nursing homes; and
• Registered nurses: 63.2 percent turnover in Green House homes versus 140.7 percent in traditional nursing homes.

Those results build on existing research indicating greater staff longevity, along with comparable levels of staff stress, satisfaction, and safety perceptions, compared to traditional homes. CNAs assigned to a single Green House home have broadened roles, including, cooking, housekeeping, personal laundry, personal care to residents, implementation of care plans, and assisting residents to spend time according to their preferences. Because of this cross-training of staff, there are also fewer specialized task workers moving in and out of the home, thus reducing risk of disease transmission.

Sustained Occupancy. The pandemic adversely impacted nursing home occupancy as safety concerns rapidly mounted, but Green House homes sustained and even increased their census figures during that time. The average census in Grown House homes from 2021 to 2022 rose slightly, from 84.8 percent to 87.9 percent, while national data showed average nursing home census declining from 71.1 percent to 70.6 percent.

Quality. The use of single rooms, by itself, has been shown to have enormous positive consequences. Besides better infection control, single rooms “enhance residents’ sense of home, privacy, and control” in long-term care settings and are “associated with improved sleep patterns and reduced agitation and aggressive behavior among people with dementia.”

The Green House homes, in particular, have shown improvement in several other quality indicators when compared to traditional nursing homes. An early study comparing residents’ reported outcomes in Green House homes to those of two traditional nursing homes reported:

• greater satisfaction with their institution as a “place to live,”
• lower rates of depression, reduced activity, and decline in functional abilities,
• higher likelihood of participating in social outings off the grounds, and
• higher scores on emotional well-being indicators.

A related study focusing on residents’ families found that Green House families reported higher satisfaction with their loved one’s care and with their own experience as family members. At the same time, they experienced no greater family burden.

A study focusing on staffing time reported that direct care staff spend 24 minutes more per resident day in direct care activities than CNAs in traditional nursing facilities without increasing overall staff time.

A 2016 review of primary and secondary data sources found that, while conformity to the Green House model varied across facilities, Green House homes overall demonstrated reductions in hospital readmissions, three minimum data set measures of poor quality, the number of bedfast and catheterized residents, and the number of pressure ulcers in low-risk residents.

Financial Viability. Green House homes have been shown to operate at median costs similar to the national median value for nursing homes. They incur modestly more capital costs compared to traditional nursing homes mainly due to increased square footage requirements per resident, but these costs are in part compensated for by higher percentage occupancy gains of Green House homes.

A study of the Green House home impact on Medicare shows potential cost saving. An analysis of residents of Green House homes showed that the Green House model significantly reduced overall annual Medicare Part A spending.

What Will It Take To Redesign Existing Nursing Home Facilities?

According to the Green House homes Senior Director Susan Ryan, Green House and related small homes continue to grow in numbers but still make up a small fraction of the skilled nursing home supply. In a dollar-driven industry, financial incentives are needed to turn the tide. These can and should be both state and federal in the form of subsidized development and re-development financing programs and enhanced Medicare and Medicaid reimbursement incentives for small household models that provide single rooms and meet quality standards. The stick of regulation will also be needed to ensure a gradual transition toward single rooms and bathrooms.

As the federal level, Housing and Urban Development (HUD) programs have always provided important stimuli to encourage development of both affordable housing and health care facilities. New initiatives and expanded funding under the HUD Section 232 Program could provide significant core support. This program provides mortgage insurance to finance purchase, refinance, construction, or rehabilitation of nursing homes, assisted living, and other residential care facilities.

CMS serves as the primary federal regulatory agency responsible for standard setting, reimbursement, and oversight. Any transition toward single rooms and private baths needs recognition in reimbursement rates, since the Green House model’s method of space allotment and facility design requires more space per resident. An enhanced rate for small household model homes that meet certain design/operations specs would be a major incentive for their development. Seeking additional federal funding is never easy politically, but state caregiving trends over the past several years toward home- and community-based care reduced the number of nursing home beds nationally, even before the pandemic, and that trend is expected by many to continue. So, enhanced reimbursement to small homes is offset at least in part by the reduction in costs resulting from declining numbers of nursing homes overall.

An area in which CMS has clear authority is in facility standard-setting, including room occupancy. To accompany the incentives described above, CMS could require residential care facilities to undertake a phased-in transition to single rooms and private bathrooms. CMS has already limited rooms certified after November 28, 2016, to “accommodate no more than two residents” and to have their “own bathroom equipped with at least a commode and sink.” This requirement would continue as rooms transition to single occupancy.

States have a long history of providing targeted incentives for particular kinds of development, from sports stadiums to housing, community development, historic rehabilitation, and myriad other purposes. Incentives may be in the form of mortgage subsidies, capital assistance, income tax or real estate tax breaks, enhanced payment rates for services, waiver of certain regulatory requirements, or other devices. Reimbursement rate incentives can be especially effective; Arkansas, for example, gave an increased Medicaid reimbursement rate to a provider for developing Green House homes. Providing meaningful incentives for the development or redevelopment of nursing facilities into the small household model has not been part of the discussion in most states. That needs to change.

On the side of regulatory sticks, states have direct control over nursing home licensure laws, which can go well beyond federal standards. Thus, states can require residential care facilities to transition toward single occupancy rooms and private bathrooms. However, this should be paired with significant incentives, as it may be politically difficult to achieve otherwise.

States also need to liberalize or waive certificate-of-need (CON) requirements for development/redevelopment of nursing homes toward the small household model such as Green House homes. State CON laws exist in the majority of states and consist of review processes for proposed new or expanded health facilities or services to control health care costs by curtailing unnecessary expansion or duplicative services. This is another area in which federal incentives to states may be needed to encourage state action.

Finally, any of the above options can be focused on an individual states or providers through new federal-state demonstration programs. This could include, for example, HUD targeted support for small home development and CMS enhanced reimbursement for single rooms, coupled with state waivers or modifications of CON requirements and state tracking of costs and quality indicators during the demonstration period. The goal would be to demonstrate a cost-effective model that is attractive to the nursing home industry and improves the quality of care and experience of care for the sickest and most vulnerable of our society and their families.

The number of ways forward are abundant. Only the vision and will have been lacking. None of the options described above will change the nursing home industry or resident experience overnight. This is a long-term, momentous effort. But if we’ve learned anything from the pandemic, it is that the status quo poses a serious human rights issue for which inaction is inhumane. We can and must strike a bold new course.

Author’s Note

The author is a board member of the Center for Medicare Advocacy.

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Why Nursing Homes Need A Total Redesign