We know the nursing home is broken. Here’s how to fix it
By Dr. Joycelyn Elders, Steve McAlilly, and Susan Ryan
The COVID-19 pandemic laid bare the problems baked into America’s nursing home infrastructure. These issues – low pay for frontline staff, woefully outdated buildings, “semi-private” rooms housing up to four residents – should not have come as a surprise to those within the industry, but the stories of mass illness and death thrust the problems into the political and media mainstream like never before.
Still, nearly two years after the first outbreak at a facility outside of Seattle, the dialogue has largely stalled out: Lawmakers, reform advocates, residents, and families continue to decry the state of long-term care, but there has been little momentum to translate outrage into concrete solutions.
Earlier this year, six U.S. senators – including Senate Finance Committee chair Ron Wyden and Senate Aging Committee chair Bob Casey – took a major step to break through that impasse with the introduction of the Nursing Home Improvement and Accountability Act. Among its many reform measures, the bill would create a $1.3 billion pilot program to fund the conversion of traditional nursing facilities to small-home campuses with private rooms and baths, more collaborative care teams, and an emphasis on resident-centered programming. 
Some of the provisions in the Act have been incorporated into the reconciliation bill currently being debated in Congress, but the funding has not yet made the cut. While we wholeheartedly support reforms that will protect residents’ rights and safety within the existing system, we fear that current federal action is focused solely on reactive steps that will not bring about the sweeping, transformative change that America’s elders deserve.
The proposed demonstration program aligns closely with the work of our organization, The Green House Project. Since 2003, we have worked to achieve the end of institutional nursing homes as we have known them for decades, replacing these somewhat dismal mini-hospitals with small-home cottages where no more than about a dozen elders live in private bedrooms with private bathrooms. Tight-knit caregiving teams cook and serve meals in communal kitchens, mixing socialization in with care, and residents are encouraged to make meaningful connections to each other and nature – with unfettered access to outdoor spaces.
The Green House model and culture led to substantially fewer COVID-19 infections and deaths compared to traditional facilities. But even before COVID, there was plenty of evidence that seniors and their families prefer small-home nursing campuses and in-home services to the traditional nursing home – and that those newer models provide better, more empowering care at a comparable or lower cost. So why aren’t there more of these options?
The short answer is inertia. The current status quo took decades to harden, and reform efforts thus far haven’t been able to overcome entrenched interests. But for just about every roadblock, there’s a straightforward fix. The proposed pilot program is an incredibly important start, and here’s a blueprint that decision-makers can follow to clear the path for permanent change.
Update regulations to encourage new development. Traditional nursing homes persist because rules at the state and federal levels often work, intentionally or not, to preserve them. In 35 states, certificate of need (CON) laws restrict the total number of licensed nursing home beds. These laws were initially designed to prevent a flood of low-quality facilities from entering a given marketplace and driving up overall health care spending.
Instead, they have largely served to stifle innovation and unintentionally perpetuate the status quo: Developers of new facilities must wait for older properties to close or downsize before they can even attempt to break ground on something better. State governments should explore special carve-outs that exempt small-home developments from bed-count caps, while also preventing the transfer of bed licenses to operators of traditional facilities.
Moreover, every completed Green House community represents a collaborative effort between providers and regulators to overcome a compliance bias toward traditional institutions. Simply put, it’s easy for departments of health and aging to say “no” to innovation designed to promote elder autonomy and empowerment – such as a hearth with a real fireplace, or free access to secure outdoor areas – because it does not fit the traditional check-box definition of a “nursing home.”
Unprecedented reforms require unprecedented regulatory frameworks, and now is the time to experiment boldly. This doesn’t mean the rollback of vital rules that preserve resident rights – it means making sure that regulations written to oversee a model born in the 1960s do not keep us from providing 21st-century options for today’s elders.
Offer permanent development and reimbursement incentives for small-home models. The nursing home industry frequently asserts that poor-quality care and low worker pay stem from inadequate Medicaid reimbursements. It’s true that the program was never designed to serve as the primary coverage source for long-term care services, and yet it pays for more than 60% of the residents who live in nursing facilities. It’s also true that per-day Medicaid rates often come in at less than a night at a hotel in a major city, sitting at an average of $239 per resident as of June 2021.
But we cannot simply throw more money at a broken system and expect to magically achieve the transformative changes that our elders deserve. Government payers have rolled out “value-based payment” initiatives designed to nudge nursing-home operators into providing better care with bonuses for hitting certain quality metrics, such as reduced hospitalizations, but these incremental moves have not led to major corresponding shifts in the resident experience.
Washington and state governments should jump at the opportunity presented in the recent Senate bill and provide direct incentives for operators to develop, build, and operate small-home campuses. The inputs of quality care, from private rooms to well-paid staff, mean just as much as medically defined outcomes for elders who require around-the-clock supports. The proposed $1.3 billion pilot program – or $39 million per facility – is an incredible start that The Green House Project wholeheartedly supports, and it can be replicated in state houses across the country on a permanent basis.
Embrace a full continuum of care. The impact of COVID-19 on nursing homes has rightfully spurred momentum for greater coverage of home health care services. We unequivocally support substantial expansion of home health options, because we believe that every senior deserves to receive care in the setting of their choice.
But we are troubled by calls for the complete elimination of congregate eldercare settings in favor of an exclusively home-based approach. This philosophy, while well-meaning, ignores the social aspect of living in a real community. For many people, this would mean that occasional visits from home health aides would represent their only human interactions; it also does not consider the Americans who live in dwellings that aren’t conducive to aging in place, such as walk-up apartments and multi-story homes, as well as elders without any stable housing.
COVID-19 illustrated the very real impact that loneliness and isolation have on elders’ physical and mental health, and we’re concerned that a “home health only” vision of reform would serve to lock more people away from their communities in the name of safety – just as nursing home visitation restrictions did for most of 2020 and into 2021.
Aging isn’t a destination. It’s a journey and an experience – and it should be a good one for all of us who are fortunate enough to live into old age. Home health providers and congregate living centers can work in harmony to provide a suite of services tailored to each person’s needs today, tomorrow, and 10 years from now. The idea of a communal setting isn’t the problem with long-term care; it’s the fact that for too many people, the outmoded and dehumanizing nursing home of the 1960s is the only care option available.
Creating real change won’t be easy, but it’s well past the time for sober post-mortems on what went wrong during COVID. It’s time for real action, which will take the coordinated efforts of people and institutions across this country. We’re ready to walk hand-in-hand with anyone willing to put in the work, set aside their past conceptions of eldercare, and keep people at the center of every reform.
Anything less will ensure that the victims of COVID-19 in long-term care will have died in vain – and doom future generations to countless repeats of 2020.
Dr. Joycelyn Elders is the former Surgeon General of the United States and a Green House Project board member. Steve McAlilly is the president and CEO of Methodist Senior Services and the chair of the Green House Project board. Susan Ryan is the senior director of The Green House Project.
 https://thegreenhouseproject.org/wp-content/uploads/Cost_Savings_Summary_2012.pdf, https://thegreenhouseproject.org/wp-content/uploads/Effects_of_GH-Families-Roslie_Kane.pdf,