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The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
July 16, 2020
The Health of Aging Populations Delivery System Reform COVID-19
Terry Fulmer Read Bio
Christopher F. Koller, President
Back to The Milbank Blog
This blog was copublished with The John A. Hartford Foundation
For some time, there’s been a steady drumbeat to improve quality and safety in nursing homes, and now the COVID-19 crisis is driving an all-out call for major change. The pandemic has emphasized the risks of mass infection when frail people live together in the same facilities. The risks increase when these facilities have poor access to personal protective equipment (PPE) and are staffed with dedicated personnel who are overworked and underpaid.
The headlines have been clear that our convoluted system for elder care does not work. Some refer to nursing homes as warehouses for frail older adults. This is no way for older people to live.
The current pandemic is requiring us to radically rethink our approach to long-term care. We believe that nursing homes should be shutting down. Instead, we should invest in extended care wings that are connected to acute care facilities in order to ensure that every older person who needs skilled nursing care has access to equal staffing, equipment, PPE, and all the amenities that come with the acute care system. People who need help with activities of daily living, on the other hand, should be able to stay at home, with enhanced community-based services and supports.
The problems in our system come from us forcing our nursing homes to look at older adults as two very different “lines of business.” For people moved out of acute care settings but too frail to be at home, nursing homes are “skilled nursing facilities,” providing high-intensity rehabilitative care for up to thirty days to people who in the past would recover in hospitals. Hospitals look to discharge these patients “quicker and sicker,” and Medicare and commercial insurance pay relatively reasonable rates to nursing homes providing this care.
For people who can no longer live at home, nursing homes are true “long-term care facilities,” providing habilitative care to support activities of daily living like bathing, dressing, and feeding. This care is financed with patients’ own assets until they “spend down” to Medicaid.
Because the Medicaid payments for long-term care are often inadequate, reimbursements for skilled care subsidize long-term care. Now COVID has upset the fragile balance. With fewer discharges from hospitals given the dramatic decrease in elective surgeries, nursing home beds that would usually be generating higher revenue have gone empty. The drastic cost of COVID-19 care and the concomitant supplies, cleaning services, and staffing have broken the backs of these settings. State budgets, shrinking under declining tax revenues, have left policymakers looking to decrease—not increase—Medicaid expenditures.
We think hospitals can be part of the solution, if they return to their roots of inpatient care. Although we associate hospitals with big inpatient buildings, hospitals have become “health systems” that receive well over half their revenues for outpatient services, which are more expensive and often of no better quality than those delivered by independent practitioners.
Now, in the wake of COVID, hospital service volumes are plummeting. Pleas from health system officials for people to “not be afraid to come in for your medical care”—outpatient visits, diagnostic services and ambulatory surgery—are as much motivated by health system bottom lines as by concerns for population health.
Why not put that unused capacity to better use?
An extended care wing is any section in a hospital that provides care for those older adults who have been discharged from acute care and need skilled nursing but cannot yet go home. The merits of extended care wings in hospitals were seen decades ago. In the 70s and 80s, extended care wings allowed health professionals to more effectively monitor the quality of care for those with profound dementia or diseases like amyotrophic lateral sclerosis, also known as Lou Gehrig’s disease.
More integration of Medicaid and Medicare funding would facilitate the increased use of extended care wings for patients who need rehabilitative care. Using Medicare dollars that currently go to acute care systems for long-term care would expand the spectrum of bundled payments available to include long-term services and supports that have been the domain of Medicaid.
This work won’t happen overnight. We have been aware of the aging of boomers since they were born, however. Isn’t it time to take dramatic action to ensure we have different models of care now for this generation and those to follow?
Most certainly, the goal is to have people stay at home as they age with quality care delivered by family caregivers who have the support that they need to take on the role. Our foundations have done much to address support for family caregivers, along with other organizations such as AARP and LeadingAge.
Wide deployment of extended care wings means that remaining nursing homes (if any) can focus on the needs of people who cannot stay at home but who need major levels of support and have serious limitations in their ability to provide self-care.
As we rethink nursing homes, we must also consider our nursing home workforce, which we have failed. This workforce has some of the highest turnover rates of any industry, reflecting poor working conditions, inadequate pay, limited benefits, and high rates of injury. Robots that can do the physical work that frees up people for the interpersonal and human caregiving skills cannot come fast enough. If we have robots that work in warehouses helping prepare boxes to be shipped by Amazon, why do we have people deliver linens and food trays to rooms? We have the science and skills to accelerate the change we want to see, and the time is now.
In hospitals’ three-decade rush to discharge inpatients quicker, we have burdened nursing homes with patients of ever higher acuity and greater rehabilitative challenges. We need to continue the efforts of moving toward more home- and community-based long-term services and supports. Any remaining facilities could focus on what they do well: meeting the care needs of people who cannot live at home. Hospitals in turn should be encouraged to use their extensive resources to help those who need skilled nursing care, particularly in a time of crisis such as now.
Terry Fulmer, PhD, RN, FAAN, is President of The John A. Hartford Foundation
Nov 16, 2020
May 13, 2020
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