Next Avenue: The case for defunding nursing homes and replacing them with a radically different model

By Charles Sabatino

The COVID-19 pandemic is a 9/11 moment for nursing home care. It’s time to replace the institutional model—here’s how it can be done

Just as the defund the police movement underscores the institutional racism that cries out for fundamental change, the COVID-19 pandemic ravaging nursing home residents underscores a deep-seated ageism inherent in our institutional model of nursing home care. I believe it is time to defund the institutional model and replace it with a radically different model.

Today’s typical nursing home has never come close to meeting the public’s desire for humane and dignified long-term care. Warehousing large numbers of frail elders in hospital-like buildings with residents in double or triple rooms along with staff turnover as high as 100% unavoidably creates a high risk for resident safety and compromises quality of care.

Nursing homes in the pandemic

Even before the pandemic, 82% of all nursing homes had infection prevention and control deficiencies cited in one or more years from 2013-2017, according to the U.S. Government Accountability Office. And 48% had such a deficiency in multiple years.

Despite the $90 billion paid annually by Medicare and Medicaid to nursing homes, and exacting regulatory requirements addressing quality of care and quality of life for the nation’s 1.3 million nursing home residents, we as a society have failed to keep frail elders safe — let alone in an environment that older adults look forward to residing in.

Pandemic data from the Centers for Medicare and Medicaid Services indicate that, as of the end of May, over 32,000 nursing home residents had died in the 88% of nursing homes that reported data. Other analyses have reported nursing home resident and staff deaths represent 40% of the nation’s COVID-19 deaths and in some areas, as high as 75%.

See: Undetected community transmission in N.Y. drove nursing home deaths, report says

As a result, multiple recommendations for change have gained attention. They include ensuring adequate personal protective equipment in nursing homes; disaster plans that facilitate quarantining; more and better trained staff and heightened monitoring and oversight of care.

But let’s be clear: These measures do little more than rearrange the deck chairs in a failing system.

The COVID-19 pandemic is a 9/11 moment for nursing home care and a test of our ability to reimagine nursing home care that puts the “home” into nursing homes.

The green house model

As the largest payer for nursing home care, Medicare and Medicaid hold the key. Now is the time to change facility requirements to gradually limit participation in the program only to facilities that provide the following:

• Small home-like facilities

• Single rooms and bathrooms

• A flattened, more flexible staff hierarchy with cross-trained staff

• A culture focused first on residents’ goals, interests and preferences

Fortunately, there is already a model for this kind of facility: the nonprofit Green House Project created by Next Avenue Influencer in Aging Dr. Bill Thomas in 2003. There are 300 Green House facilities nationally, each with 10 or 12 residents who have single rooms and private baths. Some call this “the household model.”

Don’t miss: Will COVID-19 force older workers to retire?

In The Green House, facilities are designed around a living room with a fireplace and an open kitchen where meals are prepared and shared. The cross-trained staff, backed by nurses and doctors, engage with residents, serving as nurse aides, cooks, cleaners and participants in meals and social activities. Not surprisingly, Green House staff turnover is far below that of traditional nursing homes.

Of most importance to policy makers, Green House Project homes have been proven to have high resident, family and worker satisfaction; better quality of care and quality of life than traditional nursing homes; costs comparable to traditional nursing homes and, in the midst of the pandemic, a much greater ability to prevent and contain illness.

Read: Social Security is under pressure, senior citizens are battling a health crisis — it’s not easy aging in America

Data collected in ongoing research has revealed only one resident death as of May 31 in a sample of 1,862 residents in 178 Green House homes providing skilled nursing.

As long as the nursing home industry can rely on the flow of federal money for the current model of care, it has no financial incentive to change, not even after the coronavirus catastrophe.

Change that flow, and a major cultural change in long-term care will follow.

Charles Sabatino is director of the American Bar Association Commission on Law and Aging and a Next Avenue Influencer in Aging. The views contained in this article represent Charles Sabatino’s opinions and should not be construed to be those of either the American Bar Association or the Commission on Law and Aging unless adopted pursuant to the bylaws of the Association.

This article is reprinted by permission from NextAvenue.org, © 2020 Twin Cities Public Television, Inc. All rights reserved.

Under-Enforced and OverPrescribed: The Antipsychotic Drug Epidemic Ravaging America’s Nursing Homes

Committee on Ways and Means Majority U.S. House of Representatives

Report Summary July 2020

Committee Analysis Sheds Light on Longstanding Misuse of Antipsychotics, Minimal Enforcement to Prevent Patient Harm in Nation’s Nursing Homes

Despite decades of policy and regulation aimed at reducing the misuse of chemical and physical restraints, U.S. nursing homes continue to inappropriately drug hundreds of thousands of America’s frailest and most vulnerable residents with antipsychotics. This story of patient harm, inadequate oversight, and insufficient staffing is one that continues across the country – and it is one of avoidable heartbreak.

A Ways and Means Committee analysis, “Under-Enforced and Over-Prescribed: The Antipsychotic Drug Epidemic Ravaging America’s Nursing Homes,” released on July 28, 2020, found that nursing homes continue to use antipsychotics at unnecessarily high rates. The Nursing Home Reform Act (NHRA) of 1987 outlawed the inhumane use of chemical and physical restraints for residents of skilled nursing facilities (SNFs), but the practice persists – with little enforcement on the part of the Trump Administration.

Every year, hundreds of thousands of nursing home residents are exposed to harm from the misuse of antipsychotics.

• Approximately 20 percent of all SNF residents in the United States – about 298,650 people every week – received some form of antipsychotic medication in the fourth quarter of 2019, while only about two percent had qualifying conditions for such drugs.

• Antipsychotics have a black box warning from the Food and Drug Administration, and

  the off-label use of antipsychotics can be particularly harmful for frail, elderly patients, leading to injuries, hospitalizations, and even death.

  Citations for antipsychotic misuse in SNFs increased by 200 percent between 2015 and 2017 but declined by 22 percent from 2017 to 2018 as the Trump Administration rolled back Obama-era patient protections and enforcement penalties.

• Data showed a 200 percent increase in the rate of citations for unnecessary antipsychotic

  use from 2015 to 2016, when more stringent Obama-era nursing home regulations went into full effect. From 2016 to 2017, the average national citation rate remained relatively stable, decreasing by 3.9 percent nationwide. The Trump Administration’s de-regulation campaign resulted in a 22 percent decline in citations from 2017 to 2018.

  Under the Trump Administration, little enforcement occurred even when state surveyors cited instances of patient harm. No fine was issued for 10 percent of antipsychotic-related citations for Actual Harm or Immediate Jeopardy to a resident’s health or safety.

  In 2017-2018, surveyors issued 70 citations for “Actual Harm” or “Immediate Jeopardy” across the country. Only 0.02 percent of all antipsychotic citations (41 of 5,704) from 2017-2018 documented “Actual Harm” or “Immediate Jeopardy,” despite the clear safety concerns with prescribing these medications for this population. Nearly one-fourth of these citations were associated with a fine of less than $20,000, and almost 10 percent of these citations resulted in no penalty.

JUSTICE NEWS - Department of Justice Office of Public Affairs

Tuesday, March 3, 2020

Department of Justice Launches a National Nursing Home Initiative

Attorney General William P. Barr announced today the launch of the Department of Justice’s National Nursing Home Initiative, which will coordinate and enhance civil and criminal efforts to pursue nursing homes that provide grossly substandard care to their residents. 

This initiative is focusing on some of the worst nursing homes around the country and the Department already has initiated investigations into approximately thirty individual nursing facilities in nine states as part of this effort. 

“Millions of seniors count on nursing homes to provide them with quality care, and to treat them with dignity and respect when they are most vulnerable,” said Attorney General William P. Barr.  “Yet, all too often, we have found nursing home owners or operators who put profits over patients, leading to instances of gross abuse and neglect.  This national initiative will bring to justice those owners and operators who have profited at the expense of their residents, and help to ensure residents receive the care to which they are entitled.” 

The department considers a number of factors in identifying the most problematic nursing homes.  For example, the department looks for nursing homes that consistently fail to provide adequate nursing staff to care for their residents, fail to adhere to basic protocols of hygiene and infection control, fail to provide their residents with enough food to eat so that they become emaciated and weak, withhold pain medication, or use physical or chemical restraints to restrain or otherwise sedate their residents.  These care failures cause residents to suffer in pain and to be exposed to the great indignities.  Care failures cause residents to develop pressure sores down to the bone, to lie in their own waste for hours, to starve because they cannot reach the food on their trays and to remain unwashed for weeks at a time.  Nursing homes that provide grossly substandard care also force vulnerable elderly residents who cannot leave the facilities to live in filthy and dangerous conditions where there are leaks in the roofs, mold is found growing and rodents found living in residents’ rooms.  These are some of the actions and the inactions that the department intends to pursue.

“The Department of Justice has a long history of holding nursing homes and long-term care providers accountable when they fail to provide their Medicare and Medicaid residents with even the most basic nursing services,” said Assistant Attorney General Jody Hunt for the Civil Division.  “Through this National Initiative, we will more effectively and quickly pursue nursing homes that are jeopardizing the health and well-being of their residents.”

“The Administration for Community Living was created to help ensure that older adults and people with disabilities are able to live the lives they want, with the people they choose, fully participating in their communities,” said Administrator Lance Robertson for the Administration for Community Living, U.S. Department of Health and Human Services.  “Our mission includes supporting their basic right to live with dignity, free from abuse.  We appreciate the Department of Justice’s leadership on this important Initiative, and we are proud to work side by side with DOJ and all of our partners in the Elder Justice Coordinating Council to prevent elder abuse in all forms.”

“The HHS Office of Inspector General (OIG) continues to pursue nursing home operators who provide potentially harmful care to residents who are often unable to protect themselves,” said Chief Counsel to the Inspector General Gregory Demske of HHS.  “Creating this Initiative sends a message to those in charge of caring for these beneficiaries that grossly substandard care will not be tolerated.”

The National Nursing Home Initiative reflects the department’s larger strategy and commitment to protecting our nation’s seniors, coordinated by the department’s Elder Justice Initiative in conjunction with the U.S. Attorneys’ Offices.  The Elder Justice Initiative and the U.S. Attorneys’ Offices are essential to the department’s investigative and enforcement efforts against nursing homes and other long-term care entities that deliver grossly substandard care to Medicare and Medicaid beneficiaries.  The Initiative and the U.S. Attorneys’ Offices also support the efforts of state and local prosecutors, law enforcement, and other elder justice professionals to combat elder abuse, neglect and financial exploitation, with the development of training, resources, and information. 

Learn more about the Justice Department’s Elder Justice Initiative at http://www.justice.gov/elderjustice/.