This May, the Senate Special Committee on Aging released a report on the shortcomings of nursing home oversight in the U.S. “Uninspected and Neglected” found that nearly one-third of nursing homes are behind on annual surveys, primarily as a result of underfunding and understaffing of state survey agencies.
The report’s forward concludes that the Senate investigation should serve as a “wake-up call” about the increasing strain placed on our long-term care system by population aging.
But it raises the question: After there have been so many wake-up calls as a result of the COVID-19 pandemic, are we missing the window for meaningful action in nursing home quality improvement? It’s a concern that we as members of the Moving Forward Nursing Home Quality Coalition hear often. We’re not deterred.
On July 18th, the Coalition launched our nine Action Plans – the culmination of a year of collaborative deliberations on next steps for quality improvement across the country. Here are three reasons we believe the Coalition will drive meaningful nursing home quality improvement in the year ahead.
First, we’re working on feasible, small steps in state and local settings. Each action plan describes a particular challenge facing nursing homes today, explains why it is important to residents’ quality of life, defines focused goals to address those challenges, and provides a step-by-step approach the Coalition and partners will take to achieve them over a year. Each also describes how nursing homes, state agencies, federal policymakers and others can collaborate with us in the short term.
Consider survey agency capacity. Funding and staffing are, of course, top priorities to improve survey agencies’ ability to meet their quotas. But it’s also clear that the survey process is neither as efficient nor as responsive to the concerns and experiences of residents and their care partners as it could be.
Two of the action plans address these issues – efficiency and resident responsiveness – directly. The first looks to boost surveyor training in identifying, tracking and encouraging practices of person-centered care. The second looks to collaboratively design and pilot a targeted recertification survey for nursing homes with strong, consistent evidence of high performance based on pre-survey data analytics. Ideally, a tracked approach would free up surveyors to focus more of their time on nursing homes with the highest risk or existing evidence of harm, as well as on resident and family-focused engagement.
In each case, the Coalition’s Quality Assurance Committee will collaborate with state survey teams in the design and piloting of the initiatives – with the aim of building a base for scale and spread in subsequent years.
The engagement of state leaders, nursing home providers and local advocates is what’s giving each of these action plans life in the real world.
Second, we’re piloting and amplifying great ideas and initiatives that already exist. For example, in our work on resident councils, we’re not starting from scratch. While in some nursing homes resident councils may be less effective at amplifying resident perspectives, we also know there are many successful and innovative approaches. In Connecticut, resident council presidents across the state convene as part of a statewide coalition. And the iQuality and Innovation Group at the Centers for Medicare & Medicaid Services (CMS) is piloting a new model – the Resident Family Community Advisory Council – to engage community members outside the nursing home in lifting up resident voices. Our work on resident councils builds on these efforts to help with effective scale and spread so that all residents have access to a resident council that gives them a chance to be heard.
Our action plan on ownership transparency and accountability takes a similar approach. This year CMS has taken a number of meaningful steps to improve ownership data collection at the federal level. But all 50 states also play a role in ownership transparency through licensing, Medicaid enrollment and cost reporting. Building on federal advocacy and policymaking, the Coalition is working to document ownership data policies across states, highlight trends and best practices, and develop a blueprint for state leaders to follow as they look to strengthen their own systems of transparency and accountability.
Third, we’re bringing people to the table with deep and diverse expertise and experience in nursing homes. So far over 1,000 stakeholders have raised their hands to get involved, and it’s not just the usual suspects. For example, as we’ve worked on financial incentives for the transformation of nursing homes from institutional settings to more homelike communities, we’ve been excited to bring the Department of Housing and Urban Development as well as lenders into the conversation.
The most important participants in the Coalition are nursing home residents themselves. Since our launch in September 2022, the Coalition has sought to engage residents in all our decision-making. It’s residents, for example, who told us that ownership transitions were often when quality of life and care dipped the lowest.
Residents also indicated that we’re still not having the active conversations needed about goals, preferences and priorities. Many shared that they had never had the opportunity to participate in care planning. Others shared that if they had, they didn’t have the chance to revisit whether care had met the goals they outlined. That’s why one of the Coalition’s biggest undertakings is to help make tools and resources for goal documentation, care planning, and tracking care quality more person-centered, more accessible for nursing home staff, and better integrated into regulatory and payment systems.
So we hope the answer to that concern – Have we missed our chance for action? – is clear. If you want to be part of the solution, the Moving Forward Coalition is for you. Whether you want to join the conversation or get your organization or community (no matter how small) involved in piloting meaningful change, we invite you to join us. Together, we can move nursing home quality forward.
Isaac Longobardi is the Director of the Moving Forward Nursing Home Quality Coalition.
Alice Bonner is Chair of the Moving Forward Nursing Home Quality Coalition and Senior Advisor for Aging at the Institute for Healthcare Improvement.
Jasmine L. Travers, Ph.D., MHS, RN, is an assistant professor at NYU Rory Meyers College of Nursing and affiliated faculty of the Hartford Institute for Geriatric Nursing.
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