Actionable Steps to Improve Nursing Home Operations and Patient Outcomes

Colleen O’Rourke, senior vice president, naviHealth’s Clinical and Network Solutions

The National Academies of Sciences, Engineering, and Medicine (NASEM) created a Committee on the Quality of Care in Nursing Homes to examine nursing home care in the United States. That committee has just released The National Imperative to Improve Nursing Home Quality report.

The detailed report highlights seven overarching conclusions that the committee identified:

• “The way in which the United States finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, fragmented, and unsustainable.”
• “Immediate action to initiate fundamental change is necessary.”
• “Federal and state governments, nursing homes, health care and social care providers, payers, regulators, researchers, and others need to make clear a shared commitment to the care of nursing home residents.”
• “Extreme care needs to be taken to ensure that quality-improvement initiatives are implemented using strategies that do not exacerbate disparities in resource allocation, quality of care, or resident outcomes.”
• “High-quality research is needed to advance the quality of care in nursing homes.”
• “The nursing home sector has suffered for many decades from both underinvestment in ensuring the quality of care and a lack of accountability for hose resources are allocated.”
• “All relevant federal agencies need to be granted the authority and resources from the U.S. Congress to implement the recommendations of this report.”

Addressing the Challenges Facing Nursing Homes

With such significant challenges to overcome, it can be difficult to tell where to start. Colleen O’Rourke, senior vice president of naviHealth’s Clinical and Network Solutions, notes that the challenges are so interrelated that no single problem can be fixed in isolation. “Solving the most audacious problem first, reimbursement, could have a domino effect and provide inherent improvement to the others,” she says.

She suggests that the most impactful move would be a transition to a federal long-term care benefit to provide adequate financial coverage of comprehensive nursing home care. While this would be a difficult move, it would also be impactful, supporting a well-prepared and compensated workforce. “This work must include an overhaul to both Medicare Part A reimbursement and Medicaid,” she explains. “A resident’s ability to contribute to said LTC benefit versus paying directly to the facility is an equally compelling component and should not be overlooked.”

“Medicaid is the payer of last resort and in most states the daily rates are insufficient to cover the room, board, personal and medical care needed for many residents in long-term care,” says O’Rourke. “As such, operators seek to maximize their case mix, or ratio of Medicare Part A, Private Pay and Medicaid Residents. Providers are incentivized to maximize their Medicare Part A payment to offset the financial loss from Medicaid.

“Without an appropriate reimbursement structure for long-term care, short stay payment is at risk for exploitation. Without oversight to short term stay MDS completion and billing practices, provider behavior will continue to go unchecked. It’s a broken system which must be looked at in its entirety versus in isolation.”

Actionable Steps for Nursing Homes

In addition to greater policy changes and improvements that are needed, nursing homes can also play a role in ensuring that they are able to deliver equitable care to residents. “Nursing homes need to be thinking about care and service delivery in a whole new way,” says O’Rourke. “Patient preference and active participation in care plan development is crucial to a positive patient experience. A positive patient experience will have a direct result on occupancy rates.”

She highlights the importance of flexibility in every aspect of resident care and service, including meal and menu planning, hygiene, sleep and wake times, social activities, off-campus travel, and more. “Respect, accommodation, and acceptance of an individual’s needs regardless of race, gender, sexual orientation, spirituality will be the expectation.”

O’Rourke notes that policies and regulations also need to be updated to reflect this flexibility and patient-centric approach. “For example, why shouldn’t a cognitively intact resident be allowed to keep their medications at the bedside and take them as instructed? Likewise, why is a Medicaid resident only allowed a 10 day leave of absence from the facility when a private pay resident has unlimited days?” she asks. “True patient centric care is equivalent to a door that swings both ways – our regulations need to empower our providers to meet patients where they are – not restrict patients from being their highest practical selves.”

She poses that the rigidity and failure or fear to embrace disruption can result in care that doesn’t truly serve the resident. “Operators need to feel empowered to push back on rules that feel outdated or do not serve the resident population at hand,” she says. “Operators need to feel comfortable defending patient centered care decisions when challenged by a surveyor. I am not suggesting long-term care facilities go rouge, regulations are important to ensure the health and safety of our most vulnerable. This however, should not preclude our SNF leaders from constantly asking: Why? When the regulation compromises a resident’s independence, that violates resident centric care, and the regulation needs to be challenged.”

The Value of Nursing Home Staff

O’Rourke notes the importance of remembering the importance and value of those who choose to work in nursing homes. “Strong, bright, empathetic humans unapologetically work in the nursing home industry,” she says. “I am not talking about REIT owners or even facility administrators, I am talking about direct care staff, from frontline nurses and CNAs to activity staff and dietary workers.” She highlights the fact that people choose the setting because it is a calling, and that they are fulfilling a personal purpose, not just collecting a paycheck.

“They know they could be making higher wages with better hours and less physical demands in food service or retail, yet they show up every day, with a smile, to meet the needs of our seniors,” says O’Rourke. “They must not be taken for granted they must be respected and celebrated.”

Paige Cerulli

Paige Cerulli is a contributing writer to i Advance Senior Care.